Kaiser Claim Medical Details

If you are a Kaiser Permanente member, you may be familiar with the organization's Form. This form is used to request medical care and services, and it can be used to document other information related to your health. In this blog post, we will provide an overview of the Kaiser Permanente Form, including its features and how to use it. We will also discuss some tips for completing the form correctly.

In the table, there is some good information relating to the kaiser permanente form. You may want to learn its size, the typical time needed to complete the form, the blanks you'll need to fill in, and so on.

QuestionAnswer
Form NameKaiser Permanente Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namespermanente claim form, kaiser permanente submit claim form, kaiser claim medical, permanente claim

Form Preview Example

Kaiser Foundation Health Plan, Inc.

California Division

CLAIM FOR EMERGENCY MEDICAL SERVICES

For complete information about your emergency benefits or applicable copayments, deductibles or coinsurance that are your responsibility, please refer to your Evidence

of Coverage booklet.

Note: 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 for Kaiser Foundation Health Plan to pay the difference. Complete the attached Claim for Emergency Medical Services form and mail it along with a copy of your other plan’s paid explanation of benefits. Also attach a copy of all related bills. Please refer to your Evidence of Coverage for additional information on this process.

Instructions

To request reimbursement for emergency services received at a non-Kaiser Permanente facility:

1.Complete both sides of the attached Claim for Emergency Medical Services form.

2.Attach additional information, if applicable, that is requested on the back of the Claim for Emergency Medical Services.

3.Detach and keep this instruction sheet and make a copy of the Claim for Emergency Medical Services form for your records.

4.Date and sign the form.

5.Mail your completed form, along with any bills, to one of the following addresses:

For Southern California Members:

For Northern California Members:

Kaiser Foundation Health Plan, Inc.

Kaiser Foundation Health Plan, Inc.

Claims Department

Claims Department

P.O. Box 7004

P.O. Box 12923

Downey, CA 90242-7004

Oakland, CA 94604-2923

We will process your claim upon receipt of this completed form. If we need additional information, we will notify you. For information about our time frames for processing your claim, please refer to your Evidence of Coverage.

If you have any questions or need assistance, please call our Member Service Call Center at 1-800-390-3510.

98700 (REV. 4-04) NCAL (FOR SPANISH USE 09831-001)

5506-0021-01

NS-9399 (REV. 4-04) SCAL (FOR SPANISH USE NS-9363)

 

Kaiser Foundation Health Plan, Inc.

California Division

CLAIM FOR EMERGENCY MEDICAL SERVICES

MR#:

Name:

IMPRINT AREA

IN ORDER FOR YOUR CLAIM TO BE CONSIDERED FOR PAYMENT:

BOTH SIDES OF THIS FORM MUST BE COMPLETED IN FULL.

ALL ITEMIZED BILLS FOR THIS EMERGENCY MUST BE ATTACHED.

THIS FORM MUST BE SIGNED - SEE BELOW.

IN MOST CASES, PAYMENT WILL BE MADE TO PROVIDER(S) UNLESS PROOF OF PAYMENT IS FURNISHED BY THE MEMBER OR PROVIDER(S).

PATIENT NAME

LAST

FIRST

INIT

SEX BIRTH DATE

PATIENT ADDRESS

STREET

CITY

STATE

ZIP

SUBSCRIBER NAME

LAST

FIRST

INIT

RELATION TO PATIENT

 

 

 

 

 

PATIENT DAY PHONE

()

SUBSCRIBER ADDRESS

STREET

 

CITY

 

 

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

PLACE OF ILLNESS/INJURY

CITY

 

STATE/COUNTRY

INCIDENT DATE

 

TIME

a.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p.m

 

 

 

 

 

 

 

 

 

 

PLACE OF EMERGENCY CARE

CITY

 

STATE/COUNTRY

TREATMENT DATE

 

TIME

a.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p.m

 

 

 

 

 

 

 

 

IS PATIENT COVERED BY MEDICARE OR OTHER MEDICAL INSURANCE?

NAME OF POLICY HOLDER/SUBSCRIBER

 

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YES, INSURANCE COMPANY NAME

ADDRESS

 

TELEPHONE NO.

SUBSCRIBER ID NO.

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY NAME

ADDRESS

 

TELEPHONE NO

SUBSCRIBER ID NO.

 

 

 

 

 

 

 

 

 

IS MEDICAL COVERAGE PART OF THE CAR INSURANCE POLICY?

NAME OF POLICY HOLDER

 

 

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YES, AUTOMOBILE INSURANCE COMPANY NAME

ADDRESS

TELEPHONE NO.

POLICY NO.

 

 

 

 

 

 

 

 

 

 

 

MEMBER’S DESCRIPTION OF HOW THE EMERGENCY OCCURRED

WHY WAS THE PATIENT NOT TREATED AT A KAISER PERMANENTE FACILITY?

WAS AN AMBULANCE USED?

WHO CALLED THE AMBULANCE?

 

 

 

 

 

 

 

Yes No

Patient Kaiser Permanente Police/Fire Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMIT DATE

 

DISCHARGE DATE

IS THE PATIENT DECEASED?

Yes

No

 

 

 

 

 

 

 

 

 

IF HOSPITALIZED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID THE PATIENT DIE AS A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESULT OF THE EMERGENCY? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

I authorize(names of providers) to release any and all information, including medical and/or hospital records pertaining to the health care services provided to me on/between the dates listed on this Claim for Emergency Medical Services. I understand that this information is necessary to allow Kaiser Foundation Health Plan, Inc. to process my claim for payment of these services.

AUTHORIZING SIGNATURE: PARENT’S SIGNATURE IF PATIENT IS A MINOR

DATE SIGNED

98700 (REV. 4-04) NCAL (FOR SPANISH USE 09831-001)

PLEASE COMPLETE THE REVERSE SIDE

5506-0021-01

NS-9399 (REV. 4-04) SCAL (FOR SPANISH USE NS-9363)

 

 

CLAIM FOR EMERGENCY MEDICAL SERVICES (CONTINUED)

WHEN DID YOU NOTIFY KAISER PERMANENTE?

WITH WHOM DID YOU SPEAK?

NAME OF YOUR KAISER PERMANENTE DOCTOR

AT WHICH KAISER PERMANENTE MEDICAL OFFICE DO YOU RECEIVE YOUR REGULAR CARE?

WAS THE INJURY OR ILLNESS WORK-RELATED?

Yes No

IF YES, PLEASE ATTACH EXPLANATION OF PAYMENT OR DENIAL FROM THE WORKERS’ COMPENSATION CARRIER

WAS THIS INJURY THE RESULT OF A MOTOR VEHICLE ACCIDENT?

Yes No

IF YES, PLEASE SEND A COPY OF THE DRIVER’S AUTO POLICY FACESHEET IN EFFECT WHEN THE ACCIDENT OCCURRED, AS WELL AS A COPY OF YOUR OWN AUTO POLICY FACESHEET.

WAS THIS INJURY CAUSED BY SOMEONE ELSE?

IF YES, NAME OF PARTY AGAINST WHOM YOU HAVE A CLAIM

Yes No

 

POLICY NUMBER

PARTY’S INSURANCE COMPANY NAME AND ADDRESS

If you have retained an attorney, please give the attorney’s name, address, and phone number

ATTORNEY’S NAME

ADDRESS

PHONE NO.

()

Attach additional information, if applicable, that is requested on the back of the Claim for Emergency Medical Services, and make a copy of this information for your records.

Please submit the following information, if applicable, so that we may process your claim.

Please remember to include your name and Medical Record Number on each document.

For all claims:

Itemized bills

Medical records and/or reports that you may have in your possession or to which you have access Receipts of payment

Medical Record Number (that matches the medical record on your ID card)

Additional information required for foreign claims:

Original travel tickets

Original checks

Original receipts of payment

Original bank transfer statements for cash payments

98700 REVERSE (REV. 4-04) NCAL (FOR SPANISH USE 09831-001)

5506-0021-01

NS-9399 (REV. 4-04) SCAL (FOR SPANISH USE NS-9363)

 

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