Forms & Resources

With access to the secure provider website, users can view patient coverage, benefit and copay information, and check the status of referral requests online. Practitioners have access to medical information obtained from patient visits with Kaiser Permanente and a wide range of online reference tools.

Provider Demographic Request
Please submit all demographic changes in writing on company letterhead to the Provider Relations department at 855-414-2623 or email: Provider.Demographics@kp.org

Request an on-site orientation
This form lets you request a formal Kaiser Permanente on-site orientation for your practice. The form must be completed and emailed to Provider.Relations@kp.org or faxed to 855-414-2623.

Request a provider manual
Use this form to request that a Kaiser Permanente provider manual be sent to you in the mail.

External referral and authorization form
View an example of our new Kaiser Permanente referral form.

Uniform consultation referral form
Use this form to request a referral.

Behavioral Health Uniform Treatment Plan Form
Use this form to submit continuing behavioral health treatment plans.Provider

Provider Payment Dispute Resolution Form

Attestation Forms for Third Party Liability (TPL) for Medical Support Enforcement Beneficiaries
Use the following forms when billing for Maryland Medicaid TPL Medical Support Enforcement Beneficiary claims:

Professional Claims
Institutional Claims

Discharge Planning Guide and Order Forms
Utilize this guide to assist in planning transitions of care. Included are forms for discharge planning home care and durable medical equipment (DME) orders.

Behavioral Health Level of Care Workflow for Hospitals
Utilize this guide to assist in planning appropriate transitions of care for behavioral health treatment.

The Applied Behavior Analysis Reference Guide
Offers information regarding coverage of and treatment utilizing Applied Behavior Analysis (ABA), as provided to Kaiser Permanente of the Mid-Atlantic States, Inc. members.

Skilled Nursing Facilities Quick Reference Guide
A guide for skilled nursing and acute rehabilitation facilities that covers key information, including Online Affiliate access, referral and authorization processes, billing, and quality reporting requirements.

FAQs for Applied Behavior Analysis Providers
Answers frequently raised questions by Applied Behavior Analysis (ABA) providers about working with Kaiser Permanente of the Mid-Atlantic States.

For use by Providers not already in the Kaiser Permanente Network

Interested in joining the Kaiser Permanente network?

**We only accept applications for providers that provide services in the Washington, DC, Maryland, and Northern Virginia areas (eligible counties listed below). If you are outside of this area and/or not in the counties listed below, you will need to reach out to the correct Kaiser Permanente Region if you are interested in participation. We are unable to respond to any requests and/or inquiries for network participation outside of our service area**

The counties included in our service areas are:

DC/SM Counties: Calvert (partial), Charles (partial), Frederick, Montgomery, Prince George’s, Washington, DC

Baltimore Counties: Anne Arundel, Baltimore, Baltimore City, Carroll, Harford, Howard

Northern VA Counties: Alexandria City, Arlington, Caroline (partial), Culpeper (partial), Fairfax, Fairfax City, Falls Church City, Fauquier (partial), Fredericksburg City, Hanover (partial), King George (partial), Loudoun, Louisa (partial), Manassas City, Manassas Park City, Orange (partial), Prince William, Spotsylvania, Stafford, Westmoreland (partial)

For health care practitioners ONLY
Please complete all of the following:

• Application for health care practitioners
• W-9

For institutions and providers of ancillary services ONLY
Physical, Occupational, and Speech Therapists should also use this application
Please complete all of the following:

• Application for institutions and providers of ancillary services
• W-9

For Applied Behavioral Analyst (ABA) providers ONLY
Please complete all of the following:

• Application for ABA providers
• W-9

For Behavioral Health facilities and groups ONLY
Please complete all of the following:

• Application for Behavioral Health Facilities and Groups
• W-9

For use by Providers already a part of the Kaiser Permanente Network (recredentialing/location adds)

Credentialing/Recredentialing Application
Please complete the following form for credentialing/re-credentialing. This form should not be submitted in lieu of an application if you are a new provider interested in joining the Kaiser Permanente network. If you are interested in joining the network, please choose the correct application from the list above.

• Organization/facility credentialing/recredentialing application