Forms & Resources

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Forms & Resources

Below you'll find forms and resources organized by line of business or service and plan year. 2019 documents will be posted as they become available. Some forms may only be available on our secure site. If you can't find the form you need or require further assistance, please contact us.

Wellness

Access a range of tools to help your clients gain a competitive edge.

Pharmacy

View our pharmacy services.

Pharmacy Services

2019
2018

Individual and Family

Plan Information and Brochures
2019 Service Area map (PDF)
Sales Contacts for Producers (PDF)
Individual and Family Enrollment Guide and Rates (PDF)
SEP Guide (PDF)
Forms
Account Change Form (PDF)
Affidavit of Non-Tobacco Use (PDF)
Attestation of Pediatric Dental Coverage (PDF)
Dental Application (PDF)
Enrollment Application (PDF)
SEP Documentation of Triggering Event Form (PDF)
Websites
Individual and Family Plans Member Website (Kaiser Permanente's member website for individuals and families)
Tax Credit (Subsidy) Calculator (Website)
Washington Healthplanfinder (Online Exchange marketplace)

Medicare Advantage

Forms and Websites
Sales Contacts for Producers (PDF)
Medicare Advantage Part D Comprehensive Formulary (PDF)
Star Rating Flyer (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)
Enrollment Form (PDF; CMS requires that potential enrollees receive a Summary of Benefits and Star Ratings Document when given an Enrollment Form)
Service Area Map (PDF)
Scope of Appointment Form (PDF)
Summary of Benefits Vital, Essential, Optimal (HMO) (PDF)
Summary of Benefits Harbor (HMO) (PDF)
Summary of Benefits Centennial and Columbia (HMO) (PDF)
Summary of Benefits Basic (HMO) (PDF)
Summary of Benefits Key (HMO) (PDF)
Premium Pay (Website)

Individual and Family

Plan Information and Brochures
2018 Plan Rates (PDF)
Service Area Map (PDF)
Adult/Family and Pediatric Dental Benefits with Rates (PDF)
Dental Application: For Members Enrolled Direct from Kaiser Permanente (PDF)
Enrollment Application (PDF)
KP Individual and Family Enrollment Guide & Rates (PDF)
Getting Care with Core/Kaiser Permanente Plans (PDF)
Individual and Family Plan Application (PDF)
Pediatric Dental Attestation (Direct from Kaiser Permanente Only) (PDF)
Premium Pay (Website where members can pay their premium online)
Service Area Map (PDF)
The Kaiser Permanente Approach to Health Care (PDF)
Tobacco Affidavit (PDF)
Websites
Individual and Family Plans Member Website (Kaiser Permanente's member website for individuals and families)
Tax Credit (Subsidy) Calculator ()
Washington Healthplanfinder (Online exchange marketplace)

Small Group

Plan Information and Brochures
Access PPO FAQ (PDF)
Access PPO Key Providers (PDF)
Adult/Pediatric Dental Benefits (PDF)
Compare Your Plan Options: 2017 Benefits (PDF)
Compare Your Plan Options: 2018 Benefits (effective 9/1/18 or later) (PDF)
Compare Your Plan Options: 2018 Benefits (effective before 9/1/2018) (PDF)
Getting Care with Access PPO Plans (PDF)
Getting Care with Core/Kaiser Permanente Plans (PDF)
Glossary of Health Coverage and Medical Terms (PDF)
Pediatric Dental Benefits (PDF)
Service Area Map (PDF)
The Kaiser Permanente Approach to Health Care (PDF)
Forms
Deductible & Out of Pocket Crediting Form (PDF)
Employee Enrollment and Change Form (PDF)
Enrollment/Census Template (XLS)
Quote Request Form (PDF)
Small Group Employer Application/Contract Renewal (PDF)
Waiver of Health Insurance Coverage (PDF)

Large Group

Plan Information and Brochures
Access PPO Basic Summary Grid (PDF)
Access PPO FAQ (PDF)
Access PPO HSA Summary Grid (PDF)
Access PPO Upfront Summary Grid (PDF)
Getting Care with Access PPO Plans (PDF)
Getting Care with Core/Kaiser Permanente Plans (PDF)
Health Plan Funding Options (PDF)
Provider Networks for Fully Insured Large Groups: New Sales and Renewals (PDF)
Self-Funded Overview of Core Services (PDF)
Self-Funded Overview of Reporting and Finance (PDF)
Service Area Map (PDF)
The Kaiser Permanente Approach to Health Care (PDF)
Value Prop and Access PPO Flyer (PDF)
Forms
Census Template (XLS)
Employee Enrollment and Change Form (PDF)
Group Master Application (PDF)
Underwriting Guidelines (PDF)

Medicare Advantage

Forms and Websites
KP Medicare Advantage Brochure (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)
Medicare Advantage HMO Plan Election Form (Northwest Counties) (PDF)
Medicare Advantage HMO Plan Election Form (Puget Sound) (PDF)
Medicare Advantage HMO Plan Election Form (Spokane County) (PDF)
Medicare Advantage HMO Service Area (PDF)
Medicare Advantage Part D Comprehensive Formulary (PDF)
Premium Pay (Website where members can pay their premium online)
Scope of Sales Appointment Confirmation Form (PDF)

Other

Population Health Management
Occupational Health Services
Injury Care at Kaiser Permanente Medical Offices (PDF)
Occupational Health Poster (PDF)
Overview for Employees Website ()
Overview for Employers Flyer (PDF)
Other Forms
Authorization to Disclose Health Plan Info (PDF)
Authorization to Disclose Health Plan Info (PDF)
Benefit and Prescription Claim Form (PDF)
Important Disclosure Document (PDF)
Mail-Order Pharmacy Transfer Form (PDF)
Physician Selection/Change Form (PDF)
Secure E-mail/Gateway Instructions (PDF)

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All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.

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