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Get Kaiser Permanente Member Reimbursement Claim Form
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How to fill out the Kaiser Permanente Member Reimbursement Claim Form online
Completing the Kaiser Permanente Member Reimbursement Claim Form online enables you to efficiently request a reimbursement for out-of-pocket medical expenses. This guide provides clear, step-by-step instructions to aid you in successfully filling out the form.
Follow the steps to complete your claim form correctly and efficiently.
- Press the ‘Get Form’ button to obtain the Kaiser Permanente Member Reimbursement Claim Form and open it in your editor.
- Provide the patient’s information in Section A, including the last name, first name, patient address, city, birthdate, initial, state, zip code, and medical record number found on the ID card.
- Indicate if the patient has other health insurance coverage by selecting 'Yes' or 'No.' If ‘Yes’, fill out Section C with the relevant details.
- Specify whether the service was due to an auto accident. Select 'Yes' or 'No.' If ‘Yes,’ complete Section D with the necessary information.
- In Section B, ensure you prepare an itemized bill from your provider. This must include the provider's name and address, tax identification number, amount charged for each service, place of service, procedure code, diagnosis code, name of the patient, service provided, dates of service, national provider identifier, and proof of payment.
- In Section C, if applicable, fill out the information regarding other coverage by providing the name and address of the other insurance, subscriber ID number, group number, employer name, and the insurance telephone number.
- If services are related to an automobile accident, complete Section D by entering the automobile insurance name and address, phone number, and specifying if the patient was a driver or passenger.
- For claims related to foreign or cruise travel, go to Section E and ensure to provide required documentation such as proof of payment, pharmaceutical payment proof, and travel documentation.
- Sign and date the form in Section F. If the patient is a minor or legal dependent, ensure a parent or legal guardian's signature is included.
- In Section G, locate the mailing address specific to your region and send the completed form along with the itemized bill and payment receipt.
- Finally, keep a copy of your filled-out form and all documents for your records before mailing.
Complete your claim form online today and streamline your reimbursement process.
Kaiser Permanente typically takes two to four weeks to process reimbursement claims after receiving your completed Kaiser Permanente Member Reimbursement Claim Form. Various factors can affect this timeline, such as claim volume and accuracy of the submitted information. To enhance efficiency, ensure your claim form is filled out correctly and includes all required documentation.
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