Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information, including your name, date of birth, and medical record number. This information helps to identify your application.
3. Next, provide your contact details, including your phone number, Social Security Number, and address. Ensure accuracy to facilitate communication regarding your application.
4. Indicate your household size by specifying the number of individuals living with you who will be considered in your application. This includes family members and other relevant individuals.
5. Complete the household income section by detailing your total gross income for all family members. Check all applicable income sources, such as employment, business income, or unemployment benefits.
6. Input your total out-of-pocket healthcare costs incurred over the previous twelve months for eligible services. Be sure to include applicable expenses like copays and coinsurance.
7. List all household members applying for the program, providing their names, dates of birth, relationships, and medical record numbers as necessary.
8. If you do not have health insurance, indicate your interest in being contacted by Kaiser Permanente for assistance. This is an optional step based on your situation.
9. Review all entries for completeness and accuracy. Ensure that the information provided aligns with the supporting documents you may be required to submit.
10. Sign and date the application to confirm that all information is true and complete. This is a critical step to validate your application.
11. Once everything is completed, save your changes. You can then download, print, or share the form as necessary, depending on how you intend to submit your application.

Start filling out your Kaiser Permanente MFAP form online today and take advantage of the assistance available to you.