Request enrollment kit | Child Health Plan

Child Health Plan

Request an enrollment kit

Thank you for your interest in Kaiser Permanente Child Health Plan.

Important Notice: Kaiser Permanente Child Health Plan is closed to new membership in the following Southern California counties:

Imperial County
Kern County
Los Angeles County
Orange County
Riverside County
San Bernardino County
San Diego County
Ventura County

If your child resides in one of our Northern California service areas and you would like to apply for membership, you may submit your request for an enrollment kit on line. Your enrollment kit will include all the forms you need to apply for coverage.

Please fill out all of the information requested below, and click the "Submit" button.

To request an enrollment kit by phone, call Member Services at 1-800-464-4000 (toll free) or 1-800-777-1370 (toll-free TTY for the hearing/speech impaired).

Indicates required fields

First name			Middle initial		*	Last name

Address line 1

Address line 2

City		*	State		*	ZIP code

Please indicate where your child will be receiving care in California:
Northern California Southern California

E-mail address

Retype your e-mail address

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