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.
| Question | Answer |
|---|---|
| Form Name | Kaiser Mfap |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | kaiser financial assistance, mfa, kaiser mfa application, kp org mfaapplication |
KAISER PERMANENTE
Medical Financial Assistance Program (MFAP) and Discount Payment Program
If you need help paying for your medical services, you may be eligible for Kaiser Permanente’s Medical Financial Assistance Program or Discount Payment Program. Use this brochure to help determine if you qualify, as well as to apply for financial assistance.
The MFAP and the Discount Payment Program are discretionary programs offered by Kaiser Permanente to all patients for services that are medically necessary. Services must be received at a Kaiser Permanente hospital or physician’s office, and from a Kaiser Permanente provider. You also must apply within six months
of when you received the services you’re applying for.
The MFAP may help pay for the full cost of, or the copayment amount for, medications you receive at a Kaiser Permanente pharmacy. If you’re covered under Medicare Part D and don’t already receive a Limited Income Subsidy (LIS) discount from Medicare, you can apply for a pharmacy waiver using this application.
Applying for the Medical Financial Assistance Program (MFAP)
You must meet the following criteria to be eligible for the MFAP:
Other Payer
Types of
Special
you meet the household income requirements described above. To qualify, you’ll need to provide income documentation and copies of your
You must apply under special circumstances if:
•You’re a member of a Kaiser Permanente deductible HMO plan.
•You’re applying for durable medical equipment or access to a skilled nursing facility (in which case, a referral from a Kaiser Permanente physician is also required with your application).
Please note: Not all medical expenses qualify
for financial assistance under the MFAP. Exclusions include, but aren’t limited to, expenses for premiums and dues,
Documentation required:
•A copy of a current pay stub with
•A copy of your most recent federal tax return, with electronic submission verification or your signature (include all pages and schedules); or
•Copies of other documents to verify income, such as letters from disability, Social Security, unemployment agencies, or proof of alimony/ child support payments; or
•If you have no income, a letter of support that explains your means of living; and
•Any other documentation that may be requested.
If your family size is:
1
2
3
4
Your annual income at
300% of FPG is equal to:
$32,670
$44,130
$55,590
$67,050
Your annual income at
350% of FPG is equal to:
$38,115
$51,485
$64,855
$78,225
Your annual income at
400% of FPG is equal to:
$43,560
$58,840
$74,120
$89,400
Be sure to send only photocopies, as originals will not be returned to you. You’ll have an opportunity to appeal the decision if your application is denied. Corrected and/or additional documentation will be required to support your appeal request.
The MFAP may include waivers by Kaiser Permanente pharmacies of member cost sharing for medications covered under Medicare Part D.
Applying for the Discount
Payment Program
You must meet the following criteria to be eligible for the Discount Payment Program:
•You must be uninsured and ineligible for all other public programs, such as
•Your household income must be between 351 and 400 percent of the Federal Poverty Guidelines (FPG).
•You must be receiving medically necessary care and all services must be provided
by a Kaiser Permanente hospital or medical provider.
•You must meet all documentation requirements listed in the “Applying for the Medical Financial Assistance Program (MFAP)” section of this brochure.
Kaiser Permanente reserves the right to amend or retract awards.
Submit your application to:
Medical Financial Assistance Program and Discount Payment Program
PO Box 7086
Pasadena, CA
Phone:
Fax:
Hours:
Help in Your Language
Interpreters are available 24 hours a day, seven days a week, at no cost to you. We can also provide you, your family, and your friends with any special assistance needed to access our facilities and services. In addition, you may be able to
get materials written in your language. For more information, call our Member Service Call Center at
Ayuda en su propio idioma
Tenemos disponibles intérpretes 24 horas al día, 7 días a la semana, sin ningún costo para usted. También podemos ofrecerle a usted, sus familiares y sus amigos cualquier tipo de ayuda que necesiten para tener acceso a nuestras instalaciones y servicios. Además, usted puede obtener materiales escritos en su idioma. Si desea obtener más información comuníquese con nuestra Central de Llamadas de Servicio
a los Miembros al
7 p.m. entre semana, y de 7 a.m. a 3 p.m. los fines de semana. Las personas sordas, con problemas auditivos o del habla, pueden comunicarse con el servicio TTY llamando al
Application
APPLICANT(S)
Patient name:* _________________________________________________________________________________
Medical record number:* ________________________________________________________________________
Address:* ______________________________________________________________________________________
City, State, ZIP:* ________________________________________________________________________________
Social Security number: _________________________________________________________________________
Phone number:* _______________________________________________________________________________
Date of birth:*__________________________________________________________________________________
Marital status: Married Divorced Widow(er) Single Domestic partner
Does your spouse or domestic partner need to be considered for financial assistance? Yes No
Spouse/domestic partner information:
Name: ____________________________________________________________________________________________
Medical record number: _________________________________________________________________________
Social Security number: _________________________________________________________________________
Date of birth: __________________________________________________________________________________
Household size (including yourself, your spouse or domestic partner, and all dependents):* ________________
List all household members you financially support:* (Check the box next to the name of any dependents who need to be considered for financial assistance.)
Dependent’s name __________________________________________________________________________
Date of birth _______________________ Relationship ___________________________________________
Social Security number _______________________________________________________________________
Dependent’s name __________________________________________________________________________
Date of birth _______________________ Relationship ___________________________________________
Social Security number _______________________________________________________________________
Dependent’s name __________________________________________________________________________
Date of birth _______________________ Relationship ___________________________________________
Social Security number _______________________________________________________________________
Medical facility where you get your services:* ______________________________________________________
What are you requesting financial assistance for?
Pharmacy services only
Outstanding balance for services provided within the last six months by a Kaiser Permanente provider at a Kaiser Permanente facility
Future services provided by a Kaiser Permanente provider at a Kaiser Permanente facility
Employment status:*
Currently employed? Yes No
Spouse/domestic partner employed? Yes No
*Required field
Application (continued)
SECTION A: CURRENT MONTHLY GROSS INCOME (All income from household must be reported.)
If household income is zero, please initial here____ and give a brief explaination of your financial situation.
_______________________________________________________________________________________________
Who is the primary wage earner? (check one) |
Patient |
Spouse/Other |
Gross monthly salary/wages (before taxes) |
$ _______________________ |
$ _______________________ |
Cash income (not including gifts) |
$ _______________________ |
$ _______________________ |
Gross Social Security income |
$ _______________________ |
$ _______________________ |
Other income: Unemployment benefits |
$ _______________________ |
$ _______________________ |
State disability income |
$ _______________________ |
$ _______________________ |
Alimony or child support |
$ _______________________ |
$ _______________________ |
Pension income |
$ _______________________ |
$ _______________________ |
Rental property income |
$ _______________________ |
$ _______________________ |
Other sources (describe) |
|
|
______________________ |
$ _______________________ |
$ _______________________ |
Total monthly income: |
$ _______________________ |
$ _______________________ |
SECTION B: MEDICAL EXPENSES |
|
|
|
|
|
(If your household income exceeds 350 percent of the Federal Poverty Guidelines (FPG) or if you’re applying for special circumstances, you must complete this section. Copies of receipts and/or itemized invoices are required.)
Hospital or office visits: |
$ _______________________ |
Prescribed medications: |
$ _______________________ |
Other expenses (please describe): |
$ _______________________ |
SECTION C:
If you’ve already applied for
If you answer YES to any of the questions below, contact your local County Social Security Office.
• Are you younger than 21 or older than 65? |
Yes No |
•Are you currently enrolled in Supplemental Security Income (SSI)/State Supplemental
Payment (SSP) or Security Disability Insurance? |
Yes No |
•Are you enrolled in CalWorks (AFDC), Entrant or Refugee Cash Assistance (ECA/RCA),
Foster Care or Adoption Assistance Programs, or |
Yes |
No |
• Are you legally blind? |
Yes |
No |
• Are you permanently disabled? |
Yes |
No |
• Are you pregnant or have you been pregnant in the last three months? |
Yes |
No |
• Have you been diagnosed with breast, cervical, or prostate cancer? |
Yes |
No |
• Are you being transferred to a skilled nursing facility or intermediate home care? |
Yes |
No |
• Do you have children younger than 21 (including unborn or adopted children) in the home? ... |
Yes |
No |
- If YES: Is one of the child’s parents absent or deceased? |
Yes |
No |
Is one of the child’s parents permanently disabled? |
Yes |
No |
Is the primary wage earner unemployed or working less than 100 hours |
|
|
per month? |
Yes |
No |
Application (continued)
SECTION D: LOW INCOME SUBSIDY (LIS) SCREENING (Only required if you are a Medicare Part D beneficiary.)
If you’re a Medicare Part D beneficiary with limited income and resources, you may qualify for extra help paying for your prescription drug costs. LIS provides financial assistance for eligible Medicare Part D beneficiaries who need help paying for their monthly premium, yearly deductible, prescription coinsurance and copayments, and related medical expenses.
•Are you enrolled in a Medicare savings program (QMB, SLMB, QI) where the state pays
for Medicare premiums? |
Yes No |
•Is your annual income $16,245 or less if you’re single or $21,855 or less if you’re
married and living with your spouse? |
Yes No |
•Do your resources or assets (e.g., savings accounts or investments) total less than $12,640
if you are single or $25,260 if you’re married and living with your spouse? |
Yes No |
If you’ve already applied for Medicare LIS and you have a recent denial or pending letter, |
|
please submit a copy with your MFA application. |
|
SECTION E: MISSING INCOME DOCUMENTATION
If you don’t have income documentation, your signed attestation in this application may satisfy the income verification requirement if you meet any of the following criteria:
I don’t receive a formal pay stub from my employer.
I receive no income. (If you check this box, you must provide a written explanation of your financial situation.)
I wasn’t required to file a recent Federal or State Tax Return for the most recent tax year.
SECTION F: Financial Agreement and Credit Report Authorization (Signature required.)
I hereby declare under penalty of perjury that (i) all information set forth above in this application is true and accurate in all respects, and that all attachments are accurate copies of the original documents, or (ii) I am unable to provide documents relating to proof of income or other evidence of my income. I authorize employees and agents of Kaiser Foundation Health Plan, Inc. (KFHP) and/or its affiliates to investigate and verify that information I have provided to it, including employment and credit history, for the purpose of determining my eligibility to participate in the Medical Financial Assistance Program and Discount Payment Program (together, the “Program”). I also acknowledge and agree that I am liable to KFHP for any and all amounts owing to KFHP for medical goods and services that are not covered by the Program (the “Remaining Amounts”).
In case of joint signature below, we each make the promises, representations, and authorizations set forth in the previous paragraph, including authorization and consent for employees and agents of KFHP to investigate and verify our individual and joint credit and employment histories. We also acknowledge and agree that we are each jointly and severally liable to Kaiser Permanente for the Remaining Amounts (that is, we shall each owe the Remaining Amounts to KFHP, and KFHP may collect from either or both of us an amount which does not, in total, exceed the Remaining Amounts).
Signature of Applicant/Guardian ___________________________________________ |
Date _______________ |
Signature of Spouse of Applicant/Guardian __________________________________ |
Date _______________ |
Upon finalization of your application, notification of your determination will be mailed to the address on file.
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