Fill - Free fillable Medical Claim Form (Kaiser Permanente) PDF form

SECTION

HER COVERAGE

MEMBER REIMBURSEMENT CLAIM FORM

INSTRUCTIONS: This form is to request reimbursement for services you’ve paid for out-of-pocket. For your claim

to be considered for payment, follow these simple steps:

1. Fill out this form completely and sign it.

2. Get an itemized bill from your provider detailing the charges (see Section B for the information needed in this bill).

3. Get a payment receipt for services (which can be a receipt from your provider, a copy of the check, or a bank or credit

card statement).

4. Send the form, bill, and receipt to the address for your region in Section G.

5. Keep a copy of all documentation for your records.

Contact member services with any questions about this process at the number for your region in Section G.

SECTION A: PATIENT INFORMATION

Last Name First Name Initial

Patient Address City State Zip

Birthdate (MM/DD/YYYY)

/ /

Medical Rec

ord Number found on ID Card

Does the patient have other health insurance coverage?

 Yes  No. If “Yes” complete Section C below

Was the service due to an auto accident?  Yes  No. If “Yes” complete Section D below

SECTION B: ITEMIZED BILL REQUIREMENTS

BILLS MUST BE ITEMIZED AND INCLUDE ALL OF THE FOLLOWING INFORMATION FOR REIMBURSEMENT

- Name and address of provider

(doctor, hospital, lab, ambulance service, etc.)

- Tax Identification Number (TIN)

- Amount charged for each service

- Place of service

- Procedure code

- Diagnosis code

- Name of patient

- Service provided

- Dates of service

- National Provider Indentifier (NPI)

- Proof of payment: receipt or bank statement, copies of original

check (front and back)

SECTION C: OTHER COVERAGE INFORMATION

If your primary coverage is through another medical plan, you must file your claim with that plan first. If there is a balance remaining,

after your primary medical plan pays your claim, you may file a claim with Kaiser Permanente for the difference.

Name and Address of Other Insurance

Subscriber ID Number Group Number

Employer Name

Insurance Telephone Number

( ) -

SECTION D: AUTOMOBILE ACCIDENT RELATED MEDICAL SERVICES

Automobile Insurance Name and Address Automobile Insurance Phone Number

( )

Was the patient a dr

iver or passenger?

 Driver  Pass

enger

PLEASE PROVIDE A LEGIBLE COPIES OF THE FOLLOWING DOCUMENTS:

 Copy of the auto policy face sheet for the vehicle in which the patient was riding

 Medical records and/or reports that you may have in your possession

 Please include all itemized bill requirements in section D below

SECTION E: FOREIGN/CRUISE TRAVEL REQUIRED DOCUMENTS

ALL BELOW DOCUMENTATION IS REQUIRED TO BE SUBMITTED FOR REIMBURSEMENT OF FOREIGN/CRUISE CLAIMS

- Proof of payment: Receipt or bank statement, copies of original

checks (front and back)

- Proof of pharmaceutical payment: Include on claim

form and

provide copies

- Proof of travel: Travel documentation, for example, copy of

travel itinerary and/or airline tickets

- Diagnosis code noted on claim form

- Copies of original itemized bills of service—professional,

hospital, and pharmaceutical

- Applicable medical records, including copies of original

medical report, admission notes, emergency

SECTION F: AUTHORIZING SIGNATURE

PATIENT / AUTHORIZING NAME: (PARENT’S SIGNATURE IF PATIENT IS A MINOR or LEGAL DEPENDENT)

PATIENT/ AUTHORIZING SIGNATURE: (PARENT’S SIGNATURE IF PATIENT IS A MINOR or LEGAL DEPENDENT)

SIGNATURE DATE

SECTION G: MAILING ADDRESS AND MEMBER SERVICE PHONE NUMBER

COLORADO MEMBERS

Claim Address

P.O. Box 373150

Denver, CO 80237-150

MEMBER SERVICES

1-855-364-3184

GEORGIA MEMBERS

Claim Address

P.O. Box 370010

Denver, CO 80237-150

MEMBER SERVICES

1-855-364-3185

CALIFORNIA MEMBERS

Claim Address

P.O. Box 261155

Plano, TX 75026

MEMBER SERVICES

1-800-392-8649

MD, DC OR VA MEMBERS

Claim Address

P.O. Box 261130

Plano, TX 75026

MEMBER SERVICES

1-800-392-8649

HAWAII MEMBERS

Claim Address

P.O. B

ox 261205

Plano, TX 75026

MEMBER SERVICES

1-800-392-8649

PROVIDER REIMBURSEMENT: If your request is on behalf of your provider for provider reimbursement,

please have the Provider submit charges directly to Kaiser Permanente on the CMS1500 or UB04 industry standard

claim form, which is required for processing. Please ensure your provider has your Kaiser Permanente member ID

number information and copy of your ID card.

Nondiscrimination Notice

Kaiser Permanente Insurance Company (KPIC) complies with applicable federal civil rights law

and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Kaiser Permanente does not exclude people or treat them differently because of race, color,

national origin, age, disability or sex. We also:

- Provide no cost aids and services to people with disabilities to communicate effectively with us,

such as:

o Qualified sign language interpreters

o Written information in other formats, such as large print, audio, and accessible

electronic formats

- Provide no cost language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, please call the Customer Service number on the back of your ID card.

If you believe KPIC has failed to provide these services or discriminated in another way on the basis of

race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at the

following addresses based on your Region:

Region Address / Phone Number

California

KPIC Civil Rights Coordinator, Grievance 1557, 5855 Copley Drive, Suite

250, San Diego, CA 92111

Telephone number: 1-888-251-7052 (TTY:711)

Colorado

Customer Experience Department, Attn: KPIC Civil Rights Coordinator,

2500 South Havana, Aurora, CO 80014

Telephone number:1-800-632-9700 (TTY: 711)

Georgia

Customer Experience Department, Attn: KPIC Civil Rights Coordinator,

Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736

Telephone number: 1-888-865-5813 (TTY: 711)

Hawaii

KPIC Civil Rights Coordinator, Grievance 1557, 5855 Copley Drive, Suite

250, San Diego, CA 92111

Telephone number: 1-888-251-7052 (TTY:711)

Maryland / Virginia /

Washington D.C.

KPIC Civil Rights Coordinator, Grievance 1557, 5855 Copley Drive, Suite

250, San Diego, CA 92111

Telephone number: 1-888-251-7052 (TTY:711)

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,

Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and

Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC

20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at:

http://www.hhs.gov/ocr/office/file/index.html.

KPIC-TL16-002-CA

Kaiser Permanente Insurance Company

Notice of Language Assistance

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your

language. For help, call us at the number listed on your ID card or 1-800-464-4000. For more help call the CA Dept. of Insurance

at 1-800-927-4357. TTY users call 711. English

Servicios en otros idiomas sin ningún costo. Puede conseguir un intérprete. Puede conseguir que le lean los documentos y que

algunos se le envíen en su idioma. Para obtener ayuda, llámenos al número que aparece en su tarjeta de identificación o al

1-800-464-4000. Para obtener más ayuda, llame al Departamento de Seguro de CA al 1-800-927-4357. Los usuarios de la línea TTY

deben llamar al 711. Spanish

免費語言服務。您可使用口譯員。您可請人將文件唸給您聽，且您可請我們將您語言版本的部分文件寄給您。如需協助，

請致電列於會員卡上的電話號碼或致電 1-800-464-4000 與我們聯絡。如需進一步協助，請致電 1-800-927-4357 與加州保險局

聯絡。聽障及語障電話專線使用者請致電 711。Chinese

* * * * * * * * * *

No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at

the number listed on your ID card or 1-800-464-4000. For more help call the CA Dept. of Insurance at 1-800-927-4357. TTY

users call 711. English

1-800-464-4000. CA Dept. of Insurance

1-800-927-4357. TTY 711. Navajo

Dịch vụ về ngôn ngữ miễn phí. Quý vị có thể được cấp thông dịch viên và được người đọc giấy tờ, tài liệu bằng ngôn ngữ quý

vị dùng cho quý vị nghe. Để được giúp đỡ, xin gọi chúng tôi theo số điệnthoại ghi trên thẻ ID hội viên hoặc số 1-800-464-4000.

Để được giúp đỡ thêm, vui lòng gọi Bộ Bảo hiểm CA theo số 1-800-927-4357. Người sử dụng TTY gọi số 711. Vietnamese

무료 언어 서비스. 한국어 통역 서비스 및 한국어로 서류를 낭독해 드리는 서비스를 제공하고 있습니다. 도움이 필요하신

분은 귀하의 ID 카드에 나와 있는 전화번호 또는 1-800-464-4000 번으로 문의하십시오. 보다 자세한 사항은 캘리포니아 주

보험국, 전화번호 1-800-927-4357 번으로 문의하십시오. TTY 사용자 번호 711. Korean

Mga Libreng Serbisyo kaugnay sa Wika. Maaari kayong kumuha ng tagasalin-wika at hingin na basahin sa inyo ang mga

dokumento sa sarili ninyong wika. Para humingi ng tulong, tawagan kami sa numerong nakasulat sa inyong ID card o sa

1-800-464-4000. Para sa karagdagang tulong tawagan ang CA Dept. of Insurance sa 1-800-927-4357. Dapat tumawag ang

mga gumagamit ng TTY sa 711. Tagalog

Անվճար լեզվական ծառայություններ: Դուք կարող եք օգտվել բանավոր թարգմանչի ծառայություններից և խնդրել, որ

փաստաթղթերը Ձեր լեզվով կարդան Ձեզ համար:Օգնության համար զանգահարեք մեզ` Ձեր ID քարտի վրա նշված կամ

1-800-464-4000 հեռախոսահամարով: Լրացուցիչ օգնության համար զանգահարեք Կալիֆոռնիայիապահովագրության

դեպարտամենտ` 1-800-927-4357 հեռախոսահամարով: TTY -ից օգտվողները պետք է զանգահարեն 711: Armenian

Бесплатные услуги языкового перевода. Вы можете воспользоваться услугами переводчика, при этом документы могут быть

зачитаны Вам на Вашем языке. Чтобы получить помощь, позвоните нам по телефону, указанному в Вашей идентификационной

карточке участника, или 1-800-464-4000. За дополнительной помощью обращайтесь в Департамент страхования штата

Калифорния (CA Dept. of Insurance) по телефону 1-800-927-4357. Пользователи TTY, звоните по номеру 711. Russian

KPIC-TL16-002-CA

無料の言語サービス。通訳に依頼して、日本語で書類を読んでもらうことができます。通訳サービスが必要な際は、

ID カードに記載の番号、または 1-800-464-4000 にお電話ください。さらにヘルプが必要な場合は、カリフォルニア州

保険庁（1-800-927-4357）にお電話ください。TTY ユーザーの方は、711 にお電話ください。Japanese



1-800-464-4000

1-800-927-4357TTY711 Persian

ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾ। 



  

,  '  ' 1-800-464-4000'  , 

 1-800-927-4357' TTY  711' Punjabi

សេឥតគិតលៃ។      





 ID   1-800-464-4000  







 





  1-800-927-4357  TTY  711 Khmer



1-800-464-40001-800-927-4357

Arabic

Cov Kev Pab Txhais Lus Tsis Raug Nqi Dab Tsi Koj muaj tau ib tug neeg txhais lus thiabhais tau kom nyeem cov ntaub ntawv ua koj

hom lus rau koj. Xav tau kev pab, hu rau peb ntawm tus xov toojteev muaj nyob rau ntawm koj daim yuaj ID los yog 1-800-464-4000.

Xav tau kev pab ntxiv hu rau CA Tuam Tsev Tswj Kev Pov Hwm ntawm 1-800-927-4357. Cov neeg siv TTY hu rau 711. Hmong

म

ु

त भाषा सेवाएँ। 







 , 

1-800-464-4000  



1-800-927-4357TTY 711  Hindi

  

 



ID 1-800-464-4000 





 1-800-927-4357



TTY 711. Thai

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አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል 

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Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m

Ɓàsɔ

-wùɖù-po-nyɔ

jǔ ní, nìí, à wuɖu kà kò ɖò

po-poɔ

ɓɛ

ìn m

gbo kpáa 

বাংলা (Bengali) ল� কনঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা

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(Gujarati)



 



, :









 

Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib

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ʻŌlelo Hawaiʻi (Hawaiian) E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo Hawaiʻi, hiki iā ʻoe ke loaʻa i ke kōkua

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 (Hindi)  :          



       

Hmoob (Hmong) CEEB TOOM: Yog tias koj hais lus Hmoob, muaj cov kev pab txhais lus, uas pab

dawb rau koj. 

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  

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←≡ ↑ (Laotian) ┬ε ż ź ≡δ : Θ

╒

≡↑

║

≡ Φ

║

≡α ├↑

┐

╒

≡φ ≡→≡ ←≡↑

, Ů≡α δ

╖

←

⌐

Ů≡α ź

║

↑ Ż├↓

└

─

↔ż

╒

≡α φ ≡→≡, ┬ ż Ż δ

╖

║

├→

∩

┘Ű

║

≡ ,

┤ ‼

║

α ‼

⌠

╒

↔‼ ┴↓

╒

║

≡ α . 

Kajin Majōḷ (Marshallese) LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ

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Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee

áká’ánída’áwo’dé

’, t’áá jiik’eh, éí ná hóló

. 

 (Nepali)  







:   







       



 

   

Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii,

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้

บริการช

่

วยเหลือทางภาษาได ้ฟรี โทร 

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ودر

ا (Urdu) :رادرﺑﺧ ۔ںﯾﮨ بﺎﯾﺗﺳد ںﯾﻣ تﻔﻣ تﺎﻣدﺧ ﯽﮐ ددﻣ ﯽﮐ نﺎﺑز وﮐ پآ وﺗ ،ںﯾﮨ ﮯﺗﻟوﺑ ودرا پآ رﮔا

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