Photo of three women walking and smiling

Forms

For providers
For members

Our forms directory helps you save time. You can download forms at your convenience instead of having to call us to request them.

For providers

Become a Provider

All practitioners applying for initial or continuing participation with us are required to complete an application with attestation that the information provided is accurate. We will access your web-based application and attestation via CAQH ProView™ if you are currently enrolled in this web-based program. If you are not enrolled in CAQH ProView™, the Kaiser Permanente Credentialing Department will continue to request paper copy applications. Reminder letters requesting re-credentialing applications will continue to be mailed 3 months prior to credentialing expiration. However, we encourage you to take advantage of the secure web-based CAQH ProView™ program to eliminate the time-consuming paper copy application process.

As a reminder for practitioners enrolled in CAQH ProView™, an application with attestation is due for renewal every 120 days. If the application is not current when the Kaiser Permanente Credentialing Department accesses the documentation, staff will contact you or your practice manager to update/re-attest. If the attestation in CAQH Proview™ is not updated within 15 days of the request, Credentialing staff will request a paper copy application within 7 days.

Credentialing decisions are based upon the information provided in the complete application with attestation, primary source verification of education, license, DEA, Medicare/Medicaid billing status and any reported quality/service occurrences.

You have the right to:

  - be informed of the status of your application.
  - review any information we obtained to make a credentialing determination.
  - correct erroneous information utilized to make a credentialing determination.

Please notify us when new practitioners join your group practice by contacting your provider relations representative directly, or by calling us at 877-465-0029 (toll-free). You may also email us at GA.Provider-relations@kp.org.

Patient health

Patient health questionnaire (PHQ-9)
This questionnaire helps you determine whether a patient is experiencing symptoms of depression*

PHQ-9 scoring sheet
Use this sheet to help you interpret the scores for the patient health questionnaire for depression.

Referrals

Synagis clinic referral form

Claims

Large volume claims submissions form
Use this form to submit claim concerns involving a large number of claims (25 or more).

Diagnostic studies

Request for diagnostic imaging services
Use this form to order routine diagnostic imaging services at Kaiser Permanente facilities.

Laboratory request - Front Laboratory request - Back
Download a form to request lab work.


Pharmacy

Application to add new drugs
Complete an application to add new drugs and the disclosure form to request that a new drug be added to the formulary.

Disclosure Form

Non-formulary Prescription Overview Form

Non-formulary Prescription Form


Publications

Request form for clinical practice and prevention guidelines
Submit this form if you'd like us to send you our clinical practice guidelines in the mail.

 

For members

Authorization to release or obtain PHI
Members may use this authorization form to give permission for Kaiser Permanente to obtain or release protected health information.

Advance directives for health care form
Members may complete this form to designate a health care agent and a back-up health care agent, to indicate treatment preferences, and to nominate a person to be their guardian.

You will need the free Adobe Acrobat Reader to read this file.
Please note: This PDF will open in a new window. If you can't view this PDF, please make sure that you've disabled any pop-up blockers on your computer.


* 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.