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.
Question | Answer |
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Form Name | Kaiser Permanente Form |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | permanente claim form, kaiser permanente submit claim form, kaiser claim medical, permanente claim |
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
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 |
Oakland, CA |
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
98700 (REV. |
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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 |
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PATIENT DAY PHONE
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SUBSCRIBER ADDRESS |
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STATE |
ZIP |
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PLACE OF ILLNESS/INJURY |
CITY |
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STATE/COUNTRY |
INCIDENT DATE |
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TIME |
■ a.m. |
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■ p.m |
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PLACE OF EMERGENCY CARE |
CITY |
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STATE/COUNTRY |
TREATMENT DATE |
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TIME |
■ a.m. |
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■ p.m |
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IS PATIENT COVERED BY MEDICARE OR OTHER MEDICAL INSURANCE? |
NAME OF POLICY HOLDER/SUBSCRIBER |
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■ Yes ■ No |
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IF YES, INSURANCE COMPANY NAME |
ADDRESS |
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TELEPHONE NO. |
SUBSCRIBER ID NO. |
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INSURANCE COMPANY NAME |
ADDRESS |
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TELEPHONE NO |
SUBSCRIBER ID NO. |
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IS MEDICAL COVERAGE PART OF THE CAR INSURANCE POLICY? |
NAME OF POLICY HOLDER |
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■ Yes ■ No |
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IF YES, AUTOMOBILE INSURANCE COMPANY NAME |
ADDRESS |
TELEPHONE NO. |
POLICY NO. |
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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? |
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■ Yes ■ No |
■ Patient ■ Kaiser Permanente ■ Police/Fire ■ Other (specify) |
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ADMIT DATE |
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DISCHARGE DATE |
IS THE PATIENT DECEASED? |
■ Yes |
■ No |
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IF HOSPITALIZED: |
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DID THE PATIENT DIE AS A |
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RESULT OF THE EMERGENCY? ■ Yes |
■ No |
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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. |
PLEASE COMPLETE THE REVERSE SIDE |
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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
■ 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 |
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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. |
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