How to Apply for Child Health Program – Important Deadlines

There’s a deadline to apply for Child Health Program.

Open Enrollment 2019

You may apply for Child Health Program during the open enrollment period, which runs from October 15, 2018 through January 15, 2019.

To start coverage on:
January 1, 2019
February 1, 2019

We must receive your forms by:
December 15, 2018
January 15, 2019

1. Fill out this application for health coverage

Kaiser Permanente for Individual and Families Application

For the Summary of Benefits and Coverage for the Platinum 90 – HMO plan, click here or visit, choose California, then select Platinum 90 HMO. A paper copy can be obtained at any time without charge by calling the Kaiser Permanente Member Service Contact Center number Kaiser Permante Member Services at 1-800-464-4000, TTY 711, 24 hours a day, seven days a week. You’ll need the plan name, which is stated above.

Note: Social Security numbers or tax identification numbers are NOT required to apply for the Child Health Program, but if you have one please include it on the application.

Need more help filling out the application?
Review our Child Health Program Instructions Guide for specific instructions.

2. Fill out this form for the Kaiser Permanente Child Health Program subsidy.

Kaiser Permanente Subsidy Eligibility form

Be sure to include proof of income when you mail in your child/children’s application. Here are the best ways to show proof of your income:

If you get a paycheck or direct deposit, we need:

  • your last 2 paycheck stubs, or
  • your most recent W-2, or
  • your most recent wage or tax statement

If you work for yourself, we need:

  • a Schedule C and page 1 of your last federal tax return (showing your adjusted gross income), or
  • a completed Profit and Loss Statement form

If you get paid in cash, we need:

  • a signed letter of income from your employer on company letterhead

If you have income from other sources (e.g. social security, unemployment benefits):

Need help completing the Subsidy Eligibility form? Find a local organization near you that can help.

3. Mail your completed forms and proof of income to:

Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 939095
San Diego, CA 92193-9095

Note: Mailing your forms to us does not guarantee that your child/children will be approved for the Child Health Program. We may ask you for more information to determine your child/children’s eligibility.

We’ll let you know if we can include your child/children in the Child Health Program after we receive and review your completed forms and proof of income.


* Continued eligibility for the Child Health Program is not guaranteed. We reserve the right to close enrollment or change the Child Health Program’s eligibility requirements at any time.