Get Demographic Information Form - Kaiser Permanente - Community ... - Providers Kaiserpermanente

Completing the Demographic Information Form for Kaiser Permanente is essential for proper documentation and communication within your practice. This guide offers clear, step-by-step instructions to assist you in filling out the form accurately and efficiently.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to access the Demographic Information Form and open it for editing.
2. Begin by filling out the required group information, including practice name, office manager's contact information, email address, and federal tax ID. Be sure to include a completed W-9 form as required.
3. Next, provide details for the organizational/group NPI (Type 2), notification address, and contact details such as phone and fax numbers. Also, specify the lines of business and the specialty of the group.
4. List the names of practitioners in the group, detailing any relevant specialties, hospital affiliations, and ancillary services.
5. For the individual practitioner information, fill in the required fields including last name, first name, middle initial, suffix (if applicable), professional title, and date of birth.
6. Enter the provider NPI (Type 1), gender, Medicare ID number, social security number, and medical specialty. Also, provide fluency details in languages other than English, including sign language if applicable.
7. Complete primary office information by filling in the clinical practice name, office manager's contact information, federal tax ID, and organizational/group NPI (Type 2). Include the office address, city, state, phone number, zip+4, county, and fax number.
8. If applicable, provide secondary office information in the same format. Include relevant contact details for any additional locations.
9. Fill out the pay to/remit office information with the required address, city, phone, state, zip+4, and fax number.
10. Once you have filled out all required fields, review the form for accuracy. You can then save the changes, and consider downloading, printing, or sharing the completed form as required.

Submit the Demographic Information Form online to ensure your practice is registered accurately with Kaiser Permanente.