You can keep the amount taken from your paycheck at the lowest rate if you go to a health care provider and get a checkup. A checkup is a preventive exam. To make sure the City of Portland knows you have gone to a health care provider and gotten a checkup, Kaiser Permanente needs your permission to send your name back to the City.

The City won’t get any information about your appointment, except that you had one.

• If you get a checkup, Kaiser Permanente will send you a notice in the mail and send your name, date of birth (DOB) and last four numbers of your SSN to the City.

• If you have not had the required checkup, Kaiser Permanente will send you reminders and help you make an appointment.

Kaiser Permanente will only report your name, DOB and last four numbers of your SSN back to the City.

By signing this form, you acknowledge that you have read this statement and agree to let Kaiser Permanente report your name, DOB and the last four numbers of your SSN back to the City. If you choose not to sign this form, you will not be enrolled in the Preventive Care Initiative and will not qualify for the lowest premium contribution.