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Get Kaiser Permanente Fillable Form

Kaiser Permanente Senior Advantage (HMO) GROUP ENROLLMENT REQUEST FORM Northwest Region IMPORTANT INFO Read all pages before signing this form Completing and returning this form is your first step.

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SanDiegoCA92193-9914 Questions & Answers

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Contact support

The disability examiner who handles your case will contact the doctors and hospitals listed on your application to request your medical records and other applicable documents. These records might serve as medical evidence to support your claim.

➢ To obtain the EOB and Professional Demand Bill, contact Kaiser Permanente Patient Financial Services (PFS) at 1-800-498-2748. ➢ EOBs can also be downloaded from kp.org. After logging in: o Click Coverage & Costs o Click Health plan documents o Click Go to all bills and statements documents.

Click the Save button at the bottom of the form to create a copy of your completed form as a PDF document on your computer. In the dialog box that opens, select the folder where you want to store this file and click “Save.” Do not save the file under a new name.

For Disability Insurance claims, fill out and sign Part B – Physician/Practitioner's Certificate on the Claim for Disability Insurance (DI) Benefits (DE 2501) form. Mail it in within 49 days from the date your patient's disability begins.

WASF: Work Activity Status Form is a document that verifies that a patient has been seeking or participating in treatment.

Contact 866-921-5310 (toll free) for instructions on submitting electronic claims. You may now submit appeals online via the Online Affiliate portal. Sign on or Register to access KP Online Affiliate and start using this feature today.

You can get a paper Claim for Disability Insurance (DI) Benefits (DE 2501) form by: Ordering a form onlineto have it mailed to you. Getting the form from your licensed health professional or employer. Visiting an SDI Office. Calling 1-800-480-3287 and selecting DI Information option 3 to request a paper form by mail.

In order to be eligible for DI benefits, you must: Be unable to do your regular or customary work for at least eight days. Have lost wages because of your disability. Be employed or actively looking for work at the time your disability begins.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232