Tualatin Valley

Location

333 S 1st Ave | Hillsboro, OR 97123

Free Consultation

(971) 238-5755

Patient Portal

KAISER PERMANENTE Member Reimbursement Form

Lets Create Progress Together

Health Benefits KAISER PERMANENTE Member Reimbursement Form

If you have not paid the provider, DO NOT USE THIS FORM. Ask the provider to bill us directly using a CMS 1500 or UB-04 claim form.
Make sure the provider has your Kaiser Permanente membership information.
If you have a claim for outpatient prescription drugs covered by Medi-Cal Rx, DO NOT USE THIS FORM. Please contact the Medi-Cal Rx Customer Service Center (CSC) at (800) 977-2273, 24 hours a day, 7 days a week. TTY users can call 711, Monday through Friday, 8 a.m. to 5 p.m.
Reimbursement requests cannot be combined. Submit a form for each individual reimbursement.

Instructions:

Fill out this form to request reimbursement for amounts you PAID the provider.
Fill out the form completely and sign it. Send all required documents. Incomplete or unsigned forms will be returned to you.
If you are filling out the form on behalf of someone else, please attach either a Power of Attorney Form or Authorization of Representation Form. (Parents do not need to submit these additional forms if signing on behalf of minor children or legal dependents.)
Keep a copy of this form and all documents for your records
For questions or help with this form, please call Member Services at the number listed on page 3
If you are seeking reimbursement for a COVID-19 home antigen test, please fill out the fourth page of this document. If you are not seeking reimbursement for a COVID-19 home antigen test, you can skip all questions on page four.

SECTION A: Patient information

Last Name

First Name

M.I

Home Address

City

State

Zip

Mailing Address

Check if the same as the home address

City

State

Zip

Date of Birth (mm/dd/yyyy)

/ /

Date Medical Record Number/Health Record Number (found on ID card)

SECTION B: Explanation of treatment (optional)

Please describe the services you received. Explain why treatment was not done at Kaiser Permanente.

Was the patient admitted to the hospital?

yes

If “YES” - Admit Date (mm/dd/yyyy)

/ /

If “YES” - Discharge Date (mm/dd/yyyy)

/ /

Was the patient admitted to the hospital?

yes

Unsure

SECTION C: Required information for Reimbursement

To prevent processing delays, you MUST provide the following information:

Proof of Payment: We need proof you paid the provider. Send us your receipt, bank statement, copies of original checks (front and back), or any other documents showing how much you paid the provider; AND
Provider’s Bill: Send us a copy of the provider’s bill you paid. Please include all pages and any detailed billing statements. If you do not have a copy of the bill, please provide the following information:

Name of Patient and medical record number
Dates of service
Name of provider (doctor, hospital, ambulance service, pharmacy, laboratory, etc.)
Address where service was provided (hospital address, doctor address, etc.)
Services provided to you (X-ray, office visit, injection, etc.) If a prescription, name of drug
Amount billed

Note: All documents and information submitted must be legible or the form will be returned.

SECTION D: Cruise or foreign travel reimbursement required documentation

Note: All documents and information submitted must be legible or the form will be returned.

Was the service provided during a cruise or foreign travel?

yes

If “NO” please skip. If “YES”, please provide the following information.

Proof of travel: Travel documents; such as a copy of airline tickets or a travel itinerary (optional)

Copies of original, detailed bills or service (doctor, hospital, and prescriptions)

Any related medical records, including copies of medical reports, hospital admission notes, emergency room notes, etc.

Proof of payment for services received, including prescriptions (receipt or bank statement, copies of front and back of checks, or any other documents showing how much you paid the provider)

Note: All documents and information submitted must be legible or the form will be returned.

Patient Signature

I certify that the information provided on this form is correct to the best of my knowledge. I authorize the release of all information related to the health care services I received on the dates listed on this form. I understand that this information is necessary to allow Kaiser Foundation health Plan, Inc., to process my claim for payment.

Patient/Authorizing name (parent’s name if patient is a minor or legal dependent)

Patient/Date signed

Best contact/telephone number

Reimbursement mailing addresses and Member Services phone numbers

COLORADO

Claim Address

P.O. Box 373150
Denver, CO 80237-9998

Member Services

1-303-338-3800

GEORGIA

Claim Address

P.O. Box 370010
Denver, CO 80237-9998

Member Services

1-888-865-5813

CALIFORNIA - SCAL

Claim Address

P.O. Box 7004
Downey, CA 90242-7004

Member Services

1-800-464-4000

MD, DC, or VA

Claim Address

P.O. Box 371860
Denver, CO 80237-9998

Member Services

1-800-777-7902

HAWAII

Claim Address

P.O. Box 378021
Denver, CO 80237-9998

Member Services

1-800-966-5955

CALIFORNIA - NCAL

Claim Address

P.O. Box 12923
Oakland, CA 94604-2923

Member Services

1-800-464-4000

OREGON

Claim Address

P.O. Box 370050
Denver, CO 80237-9998

Member Services

1-800-813-2000

WASHINGTON

KPWA Claim Administration

P.O. Box 30766
Salt Lake City, UT 84130-0766

Member Services

1-888-901-4636

SELF-FUNDED MEMBERS

KPIC Self-Funded Claims Administration

P.O. Box 30547
Salt Lake City, UT 84130-0547

Member Services

1-800-533-1833

COVID-19 HOME ANTIGEN TEST INFORMATION

Please fill out this portion of the member reimbursement form only if you are requesting reimbursement for a COVID-19 home antigen test. If you are requesting reimbursement for something else, you can skip this portion.

Is this reimbursement for a COVID-19 home antigen test?
Yes

No

Tests ordered online must have already shipped (not pending, not in process). Please do not request reimbursement until your tests have shipped. Has your test shipped?
Yes

No

Did you purchase the test before 1/15/22?
Yes

No
Yes: If test was purchased before 1/15/22, was the test ordered by a physician or proctored?
Physican

Proctored
No: If test was purchased after 1/15/22, was the test ordered by a physician or proctored?
Physican

Proctored

Was the test authorized for emergency use or approved by the FDA?
Yes

No

Was the test required by your employer?
Yes

No

One box or kit may have multiple tests in it. For example, one box may have two tests in it. How many total tests were purchased?

Have you already taken the test?
Yes

No
If yes, where were the results determined?
Home

Lab
Who took the test? (Please include their name, MRN, and number of tests they took)

Please include the following documentation with your request:

An itemized purchase receipt with test name, date of purchase, price, and number of tests.
Photo of the QR or UPC bar code, cut out from the testing box.
If your COVID-19 home antigen test is dated before January 15, include evidence of prescription or provider involvement.

Patient Signature

I certify that my COVID-19 home antigen test(s) were purchased for personal use, is not for employment purposes unless required by applicable state law, has not and will not be reimbursed by another source, and is not for resale.

Patient/Authorizing name (parent’s name if patient is a minor or legal dependent)

Patient/Date signed

Best contact/telephone number