Financial responsibility form 2025

1. Click ‘Get Form’ to open the financial responsibility form in the editor.
2. Begin by filling in the blank for the Plan Provider’s name, ensuring accuracy as this identifies your healthcare provider.
3. Review the reasons for ineligibility listed on the form. Check the appropriate boxes that apply to your situation, such as not being an eligible member or lacking prior authorization.
4. In the section provided, list any services that are not covered by Kaiser Permanente. Be specific to avoid confusion regarding your financial responsibilities.
5. Sign and date the form at the bottom. This confirms your understanding of your financial obligations regarding uncovered services.

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