Kaiser Medicare (formerly Silver & Fit) Renewal Requests

First Name
Last Name
Email
Phone Phone - ### - ### ####
Date of Birth Date of Birth / MM / DD YYYY
Fitness Program (If Known)

Fitness Program (If Known) I was a Kaiser Medicare Silver & Fit Y Member. [2025 Kaiser Medicare Member Fitness Membership Plans are now called One Pass and managed by Optum]
Your membership is valid at all Y locations on Oahu. What is the primary Y location you will be using?
Did you visit our YMCA today?

Did you visit our YMCA today? Yes, I visited your Y in January. Please scan me in. No, I have not visited the Y yet. Please renew my membership benefit first.
Please renew my Health Plan membership benefit using the information provided. I understand that this does not guarantee eligibility and verification must be confirmed with my health plan administrator. I will be contacted to confirm my renewal and any additional information that may be required.
Please draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.