Provider Demographics

For Provider Demographic updates please email KPCO-PDM@kp.org or FAX: 866-380-9188 the appropriate templates from the list below.


To add a new Provider to your Contracted roster:

New Practitioner Portal Template*

To request a new Place of Service be added to your Contracted Roster:

POS Add Template*

To make updates to or to terminate a Provider or a Place of Service:

Changes and Terms Template*


*This link will open a new window. If you can't view this new page, please make sure that you've disabled any pop-up blockers on your computer. Please use Google Chrome or Mozilla Firefox to download these forms. If you are unable to download and need to receive the forms directly, you may email Provider Data Management at KPCO-PDM@kp.org.

*This link will open a new window. If you can't view
this new page, please make sure that you've disabled any pop-up blockers on your
computer.Please use Google Chrome or Mozilla Firefox to download these forms. If you are unable to download and need to receive the forms directly, you may email Provider Data Management at KPCO-PDM@ kp.org.