Fillable Member Reimbursement Form (Kaiser Permanente)

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Member Reimbursement Form (Kaiser Permanente)

On average this form takes 18 minutes to complete

The Member Reimbursement Form (Kaiser Permanente) form is 4 pages long and contains:

  • 2 signatures
  • 5 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

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Member Reimbursement Form
• If you have not paid the provider, DO NOT USE THIS FORM. Ask the provider to bill us directly using a CMS 1500 or UB-04 claim form.
• Make sure the provider has your Kaiser Permanente membership information.
• If you have a claim for outpatient prescription drugs covered by Medi-Cal Rx, DO NOT USE THIS FORM. Please contact the Medi-Cal Rx Customer
Service Center (CSC) at (800) 977-2273, 24 hours a day, 7 days a week. TTY users can call 711, Monday through Friday, 8 a.m. to 5 p.m.
• Reimbursement requests cannot be combined. Submit a form for each individual reimbursement.
Instructions:
• Fill out this form to request reimbursement for amounts you PAID the provider.
• Fill out the form completely and sign it. Send all required documents. Incomplete or unsigned forms will be returned to you.
• If you are filling out the form on behalf of someone else, please attach either a Power of Attorney Form or Authorization of Representation Form.
(Parents do not need to submit these additional forms if signing on behalf of minor children or legal dependents.)
• Keep a copy of this form and all documents for your records.
• For questions or help with this form, please call Member Services at the number listed on page 3.
• If you are seeking reimbursement for a COVID-19 home antigen test, please fill out the fourth page of this document. If you are not seeking
reimbursement for a COVID-19 home antigen test, you can skip all questions on page four.
SECTION A: Patient information
Last Name
First Name MI
Home Address
City State ZIP
Mailing Address Check if the same as the home address
City State ZIP
Date of Birth (mm/dd/yyyy) Medical Record Number/Health Record Number (found on ID card)
429780066 Page 1 of 4 02/14/2022
SECTION B: Explanation of treatment (optional)
Please describe the services you received. Explain why treatment was not done at Kaiser Permanente.
Was the patient admitted to the hospital?
Yes No
If “YES” - Admit Date (mm/dd/yyyy) If “YES” - Discharge Date (mm/dd/yyyy)
Besides the amount you already paid, is the provider expecting additional payment?
Yes No Unsure
SECTION C: Required information for reimbursement
To prevent processing delays, you MUST provide the following information:
1. Proof of Payment: We need proof you paid the provider. Send us your receipt, bank statement, copies of original checks (front and back), or any
other documents showing how much you paid the provider; AND
2. Provider’s Bill: Send us a copy of the provider’s bill you paid. Please include all pages and any detailed billing statements.
If you do not have a copy of the bill, please provide the following information:
Name of Patient and medical record number
Dates of service
Name of provider (doctor, hospital, ambulance
service, pharmacy, laboratory, etc.)
Address where service was provided
(hospital address, doctor address, etc.)
Services provided to you (X-ray, ofce visit,
injection, etc.) If a prescription, name of drug
Amount billed
Note: All documents and information submitted must be legible or the form will be returned.
429780066 Page 2 of 4 02/14/2022
SECTION D: Cruise or foreign travel reimbursement required documentation
Was the service provided during a cruise or foreign travel? Yes No; If “NO” please skip. If “YES”, please provide the following information.
Proof of travel: Travel documents; such as a copy of airline tickets or a travel itinerary (optional)
Copies of original, detailed bills or service (doctor, hospital, and prescriptions)
Any related medical records, including copies of medical reports, hospital admission notes, emergency room notes, etc.
Proof of payment for services received, including prescriptions (receipt or bank statement, copies of front and back of checks,
or any other documents showing how much you paid the provider)
Note: All documents and information submitted must be legible or the form will be returned.
Patient Signature
I certify that the information provided on this form is correct to the best of my knowledge. I authorize the release of all information related to
the health care services I received on the dates listed on this form. I understand that this information is necessary to allow Kaiser Foundation
health Plan, Inc., to process my claim for payment.
Patient/Authorizing name (parent’s name if patient is a minor or legal dependent)
Patient/Authorizing signature (parent’s signature if patient is a minor or legal dependent) Date signed
Best contact/telephone number
Reimbursement mailing addresses and Member Services phone numbers
COLORADO
Claim Address
P.O. Box 373150
Denver, CO 80237-9998
Member Services
1-303-338-3800
MD, DC, or VA
Claim Address
P.O. Box 371860
Denver, CO 80237-9998
Member Services
1-800-777-7902
OREGON
Claim Address
P.O. Box 370050
Denver, CO 80237-9998
Member Services
1-800-813-2000
GEORGIA
Claim Address
P.O. Box 370010
Denver, CO 80237-9998
Member Services
1-888-865-5813
HAWAII
Claim Address
P.O. Box 378021
Denver, CO 80237-9998
Member Services
1-800-966-5955
WASHINGTON
KPWA Claim Administr ation
P.O. Box 30766
Salt Lake City, UT 84130-0766
Member Services
1-888-901-4636
CALIFORNIA - SCAL
Claim Address
P.O. Box 7004
Downey, CA 90242-7004
Member Services
1-800-464-4000
CALIFORNIA - NCAL
Claim Address
P.O. Box 12923
Oakland, CA 94604-2923
Member Services
1-800-464-4000
SELF-FUNDED MEMBERS
KPIC Self-Funded Claims Administration
P.O. Box 30547
Salt Lake City, UT 84130-0547
Member Services
1-800-533-1833
429780066 Page 3 of 4 02/14/2022
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COVID-19 HOME ANTIGEN TEST INFORMATION
Please ll out this portion of the member reimbursement form only if you are requesting reimbursement for a COVID-19 home
antigen test. If you are requesting reimbursement for something else, you can skip this portion.
• Is this reimbursement for a COVID-19 home antigen test?
Yes
No
• Tests ordered online must have already shipped (not pending, not in process). Please do not request reimbursement until your tests
have shipped. Has your test shipped?
Yes
No
• Did you purchase the test before 1/15/22?
Yes
No
• Yes: If test was purchased before 1/15/22, was the test ordered by a physician or proctored?
Physican
Proctored
• No: If test was purchased after 1/15/22, was the test ordered by a physician or proctored?
Proctored
Physican
• Was the test authorized for emergency use or approved by the FDA?
Yes No
• Was the test required by your employer?
Yes
No
• One box or kit may have multiple tests in it. For example, one box may have two tests in it. How many total tests were purchased?
• Have you already taken the test?
Yes No
• If yes, where were the results determined?
Home Lab
• Who took the test? (Please include their name, MRN, and number of tests they took)
Please include the following documentation with your request:
• An itemized purchase receipt with test name, date of purchase, price, and number of tests.
• Photo of the QR or UPC bar code, cut out from the testing box.
• If your COVID-19 home antigen test is dated before January 15, include evidence of prescription or provider involvement.
Patient Signature
I certify that my COVID-19 home antigen test(s) were purchased for personal use, is not for employment purposes unless required by applicable
state law, has not and will not be reimbursed by another source, and is not for resale.
Patient/Authorizing name (parent’s name if patient is a minor or legal dependent)
Patient/Authorizing signature (parent’s name if patient is a minor or legal dependent) Date signed
Best contact/telephone number
429780066 Page 4 of 4 02/14/2022
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Member Reimbursement Form (Kaiser Permanente)

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Completed 6 May 2022

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