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Get Hospital Bill Fillable Form

For prompt processing. Attach itemized bills from your provider. Note: See your Plan documents for applicable claims filing requirements. SEND THIS COMPLETED CLAIM FORM TO: KAISER PERMANENTE INSURANCE COMPANY (KPIC) SELF-FUNDED CLAIMS ADMINISTRATOR P.O. BOX 30547 SALT LAKE CITY, UT 84130-0547 CUSTOMER SERVICE NUMBER: 1-866-213-3062 Note: This form only needs to be completed if the provider is not submitting a claim on your behalf or you are requesting reimbursement for out of pocket expenses.

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