Forms & Resources

Our forms directory helps you save time. You can download forms at your convenience instead of visiting our facilities or calling us to request them.

Provider Dispute Single Claim Resolution Request Form

Provider Dispute Multiple Claims Resolution Request Form

CMS 1500 Form

Mental Health Teen Confidentiality

Short-Term Rehabilitation Therapy Extension Request Form

Referral Authorization Form

• Electronic Data Interchange (EDI)
  
  
• Electronic Fund Transfer (EFT) / Electronic Remittance Advice (ERA)
  
  
• Neighbor Island Network

Please Note: This content applies to the Kaiser Permanente’s Neighbor Island Networks delivery system on the islands of Kauai, Molokai and Lanai only.

Kaiser Permanente Authorization and Neighbor Island Referral form

Personal History Sheet

• Office Ally Payer ID - 94123 (360) 975-7000
  
  
• Provider Monthly Training
  • Provider Onboarding Training: every 2nd Thurs of each month from 10:00AM-11:00AM HT
  • BH After Office Hours: every 3rd Tuesday of each month from 10AM-11AM HT
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• Relay Health Payer ID = RH011