Kaiser Mfap PDF Details

Kaiser Mfap Form is an online form that Kaiser Permanente uses to collect information from their members. This form can be used to request medical or health-related services, and it helps to ensure that patients receive the care they need in a timely manner. The form is easy to use, and it can be filled out in just a few minutes. It's important to note that the Kaiser Mfap Form is only for members of Kaiser Permanente. If you're not a member, you'll need to visit your local Kaiser Permanente facility to receive care.

You can find information regarding the type of form you intend to fill out in the table. It can show you just how long it takes to finish kaiser mfap, what fields you will need to fill in and several other specific details.

QuestionAnswer
Form NameKaiser Mfap
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameskaiser mfa form, kp org mfa, kaiser mfa, kp org mfaapplication

Form Preview Example

Kaiser Permanente Medical Financial Assistance (MFA) Program

Please recycle. January 2019

Kaiser Permanente Medical Financial Assistance (MFA) Program

If you need help paying for health care services or prescriptions you’ve gotten, or are scheduled to get, from Kaiser Permanente, our MFA program may be able to help you.

How the program works

•

•

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The program offers temporary “awards” to help qualified applicants pay for care based on their financial needs.

It’s available to all Kaiser Permanente patients, whether you’re a member or not.

If awarded, the program will cover emergency or medically necessary care from Kaiser Permanente providers or at Kaiser Permanente facilities for a specified time period.

How to qualify

You must meet one of the following eligibility requirements:*

1.Your gross household income is no more than 350% of the federal poverty level.

*Note: If your gross household income is more than 350% of the federal poverty level and/or you’re a Kaiser Permanente member with a deductible plan in California, you must meet the criterion below.

2.Your out-of-pocket health care costs for emergency or medically necessary care, dental care, and medication over a 12-month period are equal to or more than 10% of your gross household income.

Out-of-pocket costs include copays, coinsurance, and deductible payments.

Out-of-pocket costs do not include any payments for your health plan itself, like your monthly premium.

Have questions?

350% of federal

poverty level guidelines

If your

Your household income

household

must be no more than:

size is:

 

 

Monthly

Annually

 

1

$3,643

$43,715

2

$4,932

$59,185

3

$6,221

$74,655

4

$7,510

$90,125

5

$8,800

$105,595

6

$10,089

$121,065

Visit aspe.hhs.gov/poverty to find the guidelines for larger households.

For more information about qualifying for the MFA program, or to see which health care services it pays for, visit www.kp.org/mfa/ncal.

If you don’t have health insurance, you may be required to apply for it.

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•

•

Because the MFA program only provides temporary financial awards, we may require you to apply for coverage that will cover you in the long term. This could include any other public or private health programs you’re eligible for — like Medi-Cal or subsidized plans available on the health insurance marketplaces.

We may ask you to show proof that you’ve applied to these programs, or that you’ve been approved or denied by them. But you may still be able to get financial help from the MFA program while waiting for a decision from these other programs.

For more information about other health coverage you may be eligible for, visit healthcare.gov or call 1-800-318-2596.

How to apply

If you meet the eligibility requirements, you can apply in any of these ways.

 

•

Complete the MFA application on the following page.

Mail it

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Mail your completed application to:

 

Kaiser Permanente MFA Program

 

 

PO Box 30006

 

 

Walnut Creek, CA 94598

 

 

 

Fax it

•

Complete the MFA application on the following page.

•

Fax your completed application to 1-800-687-9901.

 

 

 

 

Drop it off

•

Complete the MFA application on the following page.

•

Drop off your completed application at the Patient Financial

 

 

Operations at any Kaiser Permanente facility.

 

 

 

 

•

Call us at 1-800-390-3507 (TTY 711), Monday through Friday,

Call us

 

8:00 a.m. to 5:00 p.m. PST.

•

Be prepared to provide the information listed on the MFA

 

 

 

application on the next page.

 

 

 

Important: When applying by mail or fax, or dropping off your application in person, please be sure to fill out the application as much as you can. Any missing information may delay the application process.

What to expect after you apply

After we review your completed application, we’ll let you know one of the following outcomes:

•Your application was approved and you’ll get a financial award.

•To complete your application, we need additional information or paperwork, which you can send us in the mail or drop off in person; this could include proof of income or copies of your out-of-pocket expenses.

•Your application was denied and why it was denied, in which case you can appeal our decision.

Need help?

If you have any questions or need help with your application, please call 1-800-390-3507 (TTY 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. PST. You can also talk to a financial counselor at any Kaiser Permanente location.

Medical Financial Assistance (MFA) Program application

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical record #:

 

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

/

 

/

 

Contact #: (

 

 

 

)

 

 

 

 

 

 

 

 

 

SSN:

 

 

 

 

 

-

 

-

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

ZIP code:

 

 

Household size: Number of family members (including you) who live in your

 

 

 

 

 

 

 

 

 

 

 

home. May include a spouse or qualified domestic partner, children, a non-parent

 

 

 

 

 

 

 

 

 

 

 

caretaker relative, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Household income (monthly): Total gross income for all family members in the

 

 

 

 

 

 

 

 

 

 

 

household. Check ALL income types that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment Income/Wages

Alimony/Child Support

 

 

 

 

 

 

 

 

 

 

 

 

Business Income/Rental Property

Pension or Retirement/Annuities

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment Benefits/

 

Social Security/Supplemental

 

 

 

 

 

 

 

 

 

 

 

 

Disability Income

 

 

 

Security Income/Veterans Benefits

 

$_______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health care costs: Total out-of-pocket expenses you had over a 12-month period

 

 

 

 

 

 

 

 

 

 

 

for emergency or medically necessary services provided by Kaiser Permanente

 

 

 

 

 

 

 

 

 

 

 

or any other health care provider. May include copays, deposits, coinsurance,

 

 

 

 

 

 

 

 

 

 

 

or deductible payments for eligible medical, pharmacy, or dental services.

 

$_______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list all members of your household applying for the program.

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

Date of birth

 

 

 

Relationship

 

 

Medical record #

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

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Uninsured? Kaiser Permanente can help. If you do not have health care

 

 

 

 

 

 

 

 

 

 

 

coverage, we can help you understand your options. Check this box if you

 

 

 

 

 

 

 

 

 

 

 

would like Kaiser Permanente to contact you to discuss your options.

 

 

 

 

Yes, contact me

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby declare under penalty of perjury that all information set forth above in this application is true and accurate in all respects. I also acknowledge and agree that I am liable to Kaiser Foundation Health Plan and Hospitals for all amounts owing to Kaiser Foundation Health Plan and Hospitals for medical goods

and services that are not eligible under the Program (the “Remaining Amounts”).

Signature:

 

Date:

Note: Kaiser Foundation Health Plan and Hospitals reserves the right to use information from consumer credit reporting agencies and other third-party information sources to determine eligibility for federal, state, and private medical programs, including the MFA Program.

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