NS11793 (0123)
Page 1 of 3
MEMBER REIMBURSEMENT CLAIM FORM
INSTRUCTIONS: This form is to request reimbursement for services you've paid for out-of-pocket. For your claim
to be considered for payment, follow these simple steps:
1. Fill out this form completely and sign it.
2. Get an itemized bill from your provider detailing the charges (see Section B for the information needed in this bill).
3. Get a payment receipt for services (which can be a receipt from your provider, a copy of the check, or a bank or
credit card statement).
4. Send the form, bill, and receipt to the address for your region in Section G.
5. Keep a copy of all documentation for your records.
Contact member services with any questions about this process at the number for your region in Section G.
SECTION A: PATIENT INFORMATION
Last Name First Name Initial
Patient Address City State Zip
· Birthdate (MMDDYYYY) Medical Record Number found on ID Card
Does the patient have other health insurance coverage?
፬
Yes
፬
No. If 'Yes" complete Section C below
Was the service due to an auto accident?
፬
Yes
፬
No If 'Yes* complete Section D below and provide all
itemized bill requirements in section B below
SECTION B: ITEMIZED BILL REQUIREMENTS
BILLS MUST BE ITEMIZED AND INCLUDE ALL OF THE FOLLOWING INFORMATION FOR REIMBURSEMENT
- Name and address of provider - Name of patient
(doctor, hospital, lab, ambulance service, etc.) - Service provided
- Tax Identifi cation Number (TIN) - Dates of service
- Amount charged for each service - National Provider Identifi er (NPI)
- Place of service - Proof of payment: receipt or bank statement, copies of original
- Procedure code check (front and back)
- Diagnosis code
SECTION C: OTHER COVERAGE INFORMATION
If your primary coverage is through another medical plan, you must fi le your claim with that plan fi rst. if there is a balance
remaining, after your primary medical plan pays your claim, you may fi le a claim with Kaiser Permanente for the difference.
Name and Address of Other Insurance Subscriber ID Number Group Number
Employer Name Insurance Telephone Number
() -
Kaiser Permanente Insurance Company
NS11793 (0123) Page 2 of 3
MEMBER REIMBURSEMENT CLAIM FORM
SECTION D: AUTOMOBILE ACCIDENT RELATED MEDICAL SERVICES
Automobile Insurance Name and Address Automobile Insurance Phone Number
( ) -
Was the patient a driver or passenger?
፬
Driver
፬
Passenger
PLEASE PROVIDE A LEGIBLE COPIES OF THE FOLLOWING DOCUMENTS:
Copy of the auto policy face sheet for the vehicle in which the patient was riding Medical records and/or reports that you may have in your
possession
Please include all itemized bill requirements in section B above
SECTION E: FOREIGN/CRUISE TRAVEL REQUIRED DOCUMENTS
ALL BELOW DOCUMENTATION IS REQUIRED TO BE SUBMITTED FOR REIMBURSEMENT OF FOREIGN/CRUISE CLAIMS
- Proof of payment: Receipt or bank statement, copies of original - Diagnosis code noted on claim form checks (front and back)
- Proof of pharmaceutical payment: Include on claim form and - Copies of original itemized bills of service—professional, provide
copies hospital, and pharmaceutical
- Proof of travel: Travel documents for example copy of travel - Applicable medical records, including copies of original Itinerary
and/or airline tickets medical report, admission notes and emergency notes
SECTION F: AUTHORIZING SIGNATURE
PATIENT /AUTHORIZING NAME: (PARENT'S SIGNATURE IF PATIENT IS A MINOR or LEGAL DEPENDENT)
PATIENT/ AUTHORIZING SIGNATURE: (PARENT'S SIGNATURE IF PATIENT IS A MINOR or LEGAL DEPENDENT)
SIGNATURE DATE
SECTION G: MAILING ADDRESS AND MEMBER SERVICE PHONE NUMBER
COLORADO MEMBERS
Claim Address
P.O. Box 373150
Denver, CO 80237-9998
MEMBER SERVICES
1-855-364-3184
GEORGIA MEMBERS
Claim Address
P.O. Box 370010
Denver, CO 80237-9998
MEMBER SERVICES
1-855-364-3185
HAWAII MEMBERS
Claim Address
P.O. Box 378021
Denver, CO 80237-9998
MEMBER SERVICES
1-800-238-5742
MD, DC OR VA MEMBERS
Claim Address
P.O. Box 371860
Denver, CO 80237-9998
MEMBER SERVICES
1-888-225-7202
NORTHERN CA MEMBERS
Claim Address
P.O. Box 12923
Oakland, CA 94604-2923
MEMBER SERVICES
1-800-788-0710
SOUTHERN CA MEMBERS
Claim Address
P.O. Box 7004
Downey, CA 90242-7004
MEMBER SERVICES
1-800-788-0710
Kaiser Permanente Insurance Company
NS11793 (0123) Page 3 of 3
MEMBER REIMBURSEMENT CLAIM FORM
For your protection California law requires the following to appear on this form: Any person who knowingly
presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fi nes and
confi nement in state prison.
PROVIDER REIMBURSEMENT: If your request is on behalf of your provider for provider
reimbursement, please have the Provider submit charges directly to Kaiser Permanente on
the CMS1500 or UB04 industry standard claim form, which is required for processing. Please
ensure your provider has your Kaiser Permanente member ID number information and copy of
your ID card.
