Forms and publications – Kaiser Permanente Washington

Find information on services and features related to your plan, including coverage information, member guide booklets, and authorization-of-care forms for you or a loved one. For notices and updates, including holiday hours, click here. For information on our Medicare Advantage plans, visit kp.org/medicare. Additional Medicare forms and information are available on the Learn About My Plan page and the Medicare Part D formulary page.


On this page:


Medical record access and health care information release

For Kaiser Permanente Washington only

Instructions: How to transfer and get copies of your medical records

Summary of benefits and coverage

Summary of benefits and coverage (SBC) documents summarize important information about health coverage options in a standard format developed by Health and Human Services. SBCs allow you to check plan benefits and coverage. You can also easily compare Kaiser Permanente plan benefits and coverage with other carriers.

Evidence of coverage

In our effort to assist you in making an informed decision, we are providing plan documents where you can review further details of our plans.

Specialty visit questionnaires

You may be asked to fill out a questionnaire prior to an appointment with a specialist.

Well-care questionnaires

These questionnaires need to be filled out before a well-care visit, also known as preventive care.

Family and Medical Leave Act (FMLA) & WA State Paid Family & Medical Leave

Use these forms to request medical certification for your FMLA and/or Paid Family & Medical Leave application for yourself or a family member and release information to your employer or another third party. Please note, the patient must be receiving care from a Kaiser Permanente clinician to use these forms.

Virtual care

Confidential communications

Under Washington laws you have the right to submit a Request for Confidential Communications asking Kaiser Permanente to send any communications containing your personal health information to you alone, and not to the insurance subscriber that pays for your health insurance. For example, you can request that explanation of benefits (EOB), notices of adverse benefit determinations, and other health plan information only be sent to you. There are three ways to request confidential communications:

  1. Complete and sign a Confidential Communications Request form (see the link below), and send it to:
    Attn: Member Services, P.O. Box 34590, Seattle, WA 98124
  2. Complete and sign the Confidential Communications Request form, and fax it to 1-888-874-1765
  3. Contact Member Services at 1-888-901-4636 and ask for assistance

Washington Request for Confidential Communications

WA Office of the Insurance Commissioner (OIC) Confidentiality Request Form

Member resource guides

The following member resource guides are for enrollees in each of our health plans. They are designed to help you understand your plan and how to access your care.

Individual and Family plan resources

Health Care Benefit Managers

Kaiser Foundation Health Plan of Washington (KFHPWA) and Kaiser Foundation Health Plan of Washington Options, Inc. (KFHPWAO) utilize Health Care Benefit Managers for certain services. Below is a list of Health Care Benefit Managers along with a brief description of the services they provide.

Health Care Benefit Manager (HCBM) Services Provided Carrier – KFHPWA Carrier – KFHPWAO
Cotiviti Utilization management reviews for provider payment X X
Exponent Health (formerly HRGi) Provides claims repricing X X
First Choice Health Network, Inc. Supports claims repricing and network management   X
First Health Group Corp. (First Health Network) Supports claims repricing X X
MultiPlan, Inc. Data iSight is an application for non-contracted HMO claims supporting usual and customary rates for the services provided X X
OptumInsight, Inc. Supports analysis of post adjudication prepay claims and provider reconsideration requests for related claim denials X X
OptumRx, Inc. Provides services including pharmacy claim adjudication, direct member reimbursement processing, accumulator tracking and reconciliation, benefit plan/formulary set up and maintenance, pharmacy network maintenance, call center to support for all pharmacies and member calls. X X
Quantify Health Provides medical necessity and billing reviews of high dollar claims X X
Radiant Services, LLC Performs utilization management reviews, claims quality audits, claims processing, and external audit support X X
WholeHealth Living, Inc (Tivity Health) Supports chiropractic utilization management reviews and network management X X

Pre-authorization requirements 

Kaiser Permanente requires pre-authorization for some services to be covered. Some requests for pre-authorization and/or claims will be reviewed by a clinician for medical necessity. The criteria used to determine medical necessity is available on our Provider site.

For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage, or contact Member Services toll-free at 1-888-901-4636.

Parental access forms

Instructions: Request access to your child's online record - From birth through age 17; access changes on child's 13th birthday

Enrollment and change forms

Pharmacy and medical reimbursement forms

Instructions and forms: How to submit claims for reimbursement - For both Medicare and non-Medicare claims, as well as foreign claims.
 

Pharmacy forms

Claim forms

Accident and injury questionnaires

Please contact The Rawlings Company at 1-855-967-6607 or visit the Rawlings website to complete accident and injury questionnaires.

For existing cases prior to June 15, 2022, leave a voicemail message with Kaiser Permanente Other Party Liability line at 1-866-783-9594. For personal injury protection or workers compensation forms submitted through Kaiser Permanente clinics, contact Patient Financial Services at 1-800-442-4014.

Other claim forms

Informed consent forms

Hospice Policies

Advance Directives

Billing forms


 

*To protect the security of personal information, you must sign on to the member website to use these online forms. This helps us process your request more quickly. (To sign on, you need to be registered.) 

If you don't want to sign on, in some cases, there is also a PDF version of the same form. However, you must print the PDF, fill it out, and send it via postal mail. For security reasons, PDFs cannot be submitted as email attachments.

**You can refill and transfer prescriptions online by signing on to the member website. (To sign on, you need to be registered.)