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Cigna Providers Outside a Kaiser Permanente State (Outside CA, CO, DC, GA, HI, MD, OR, VA, WA)

Forms

Pharmacist reviews label with woman

Download forms

Instructions for Pre-Authorization Form (PDF)

Dual Choice PPO Pre Certification List (PDF)

Acute Care UM Hospital Timely Notification Policy (PDF)

Authorization for Medical Care (PDF)
The Authorization for Medical Care will be faxed and/or mailed to provider offices to notify them that a Kaiser Permanent Northwest member has been referred to them for medical care.

Explanation of Payment (EOP) (PDF)
The Kaiser Permanente Explanation of Payment is sent to providers to inform them of how a claim was adjudicated.

Specialty Radiology Form (PDF) and Radiology Form (PDF)
Please use the attached forms when ordering Radiology Services from Kaiser Permanente.

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