Forms and Resources

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Forms & Resources

Below you'll find forms and resources organized by line of business or service and plan year. 2020 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

2020
2019

Individual and Family

Plan Information and Brochures
2020 Individual & Family Service Area Map (PDF)
Individual & Family and Medicare Sales Contact Sheet (PDF)
2020 Enrollment Guide (PDF)
2020 Special Enrollment Guide (PDF)
2020 Producer Reference Guide for Individual and Family Plans (PDF)
Forms
2020 Proof of Qualifying Life Event Form (PDF)
2020 KPIF Enrollment Application (PDF)
2020 Pediatric Dental Attestation (PDF)
2020 Affidavit of Non-Tobacco Use (PDF)
2020 Account Change Form (PDF)

Small Group

Plan Information and Brochures
Forms

Large Group

Plan Information and Brochures
Forms

Medicare Advantage

Forms and Websites
Silver & Fit Flyer (PDF)
Star Rating Flyer (PDF)
KPIF and Medicare Sales Contact Sheet (PDF)
Enrollment Form (PDF)
Summary of Benefits Key (HMO) (PDF)
Summary of Benefits Basic (HMO) (PDF)
Summary of Benefits Centennial and Columbia (HMO) (PDF)
Summary of Benefits Harbor (HMO) (PDF)
Summary of Benefits Vital, Essential, Optimal (HMO) (PDF)
Scope of Appointment Form (PDF)
Service Area Map (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)

Other

Individual and Family

Plan Information and Brochures
2019 Individual and Family Commission Supplement (PDF)
2019 KPIF Plan Guide for Producers (PDF)
2019 Service Area map (PDF)
Individual and Family Enrollment Guide and Rates (PDF)
Sales Contacts for Producers (PDF)
SEP Guide (PDF)
Forms
2019 Producer Reference Guide for Individual and Family Plans (PDF)
Account Change Form (PDF)
Affidavit of Non-Tobacco Use (PDF)
Agent of Record Form (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)

Small Group

Plan Information and Brochures
2019 Compare your plans options brochure (PDF)
Access PPO FAQ (PDF)
Access PPO Key Providers (PDF)
Compare Your Plan Options (PDF)
Getting Care with Access PPO Plans (PDF)
Getting Care with Core/Kaiser Permanente Plans (PDF)
Glossary of Health Coverage and Medical Terms (Brochure)
Rating 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)
Employee Enrollment Form and Employee Waiver (PDF)
Enrollment/Census Template (XLS)
Group Master Application (PDF)
Request a Quote (PDF)
Waiver of Health Insurance Coverage (PDF)

Large Group

Plan Information and Brochures
Access PPO Basic Benefits Grid (PDF)
Access PPO Basic Benefits Summary (PDF)
Access PPO HSA Benefits Summary (PDF)
Access PPO Upfront Benefits Summary (PDF)
Getting Care with Access PPO Plans (PDF)
Getting Care with Access PPO Puget Sound Plans (PDF)
Getting Care with Access PPO Spokane Plans (PDF)
Getting Care with Core/Kaiser Permanente Plans (PDF)
HMO Benefits Grid (PDF)
HMO HealthPays HSA Benefits Grid (PDF)
Service Area Map HMO (PDF)
Service Area Map PPO (PDF)
Forms
Census Template (XLS)
Employee Enrollment and Change Form (PDF)
Group Master Application (PDF)
Health Equity - HSA and HRA Banking Arrangement (website)

Medicare Advantage

Forms and Websites
Annual Notice of Change - Columbia plan (PDF)
Annual Notice of Change - Basic plan (PDF)
Annual Notice of Change - Centennial plan (PDF)
Annual Notice of Change - Essential plan (PDF)
Annual Notice of Change - Harbor plan (PDF)
Annual Notice of Change - Optimal plan (PDF)
Annual Notice of Change - Vital plan (PDF)

Other

Population Health Management
Occupational Health Services
Kaiser Permanente On-the-Job Clinic Locations and Maps (PDF)
Kaiser Permanente On-the-Job Strengthen Your Workforce Strategy (PDF)
Kaiser Permanente On-the-Job Supporting the Needs of Employers and Workers (PDF)
Other Forms
Authorization to Disclose Health Plan Info (PDF)
Benefit and Prescription Claim Form (PDF)
HSA Preventive Medication Flyer (PDF)
Important Disclosure Document (PDF)
Mail Order Pharmacy Resource Card (PDF)
OptumRx Claim Reimbursemet Form (PDF)
OptumRx Pharmacies (PDF)
Physician Selection/Change Form (PDF)
Secure E-mail/Gateway Instructions (PDF)

LinkedIn

YouTube

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

© 2019 Kaiser Foundation Health Plan of Washington