Non plan care 2026

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The document is a claim form for non-plan care provided by Kaiser Permanente, requiring detailed patient and subscriber information, incident details, and follow-up care. It emphasizes the importance of completing the form fully to avoid delays in processing and outlines specific instructions for claims related to work-related injuries or accidents involving third parties. Additionally, it includes a trust agreement regarding reimbursement for services related to third-party injuries.

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Click ‘Get Form’ to open the non-plan care document in the editor.
Begin by filling out the 'About the Patient/Subscriber' section. Enter the patient's name, sex, address, health record number, and Medicare status. Ensure all fields are completed accurately.
Next, provide details about the subscriber including their name, birthdate, social security number, and employer information. If the subscriber's address differs from the patient's, include that as well.
In the 'About the Non-Plan Care' section, specify where the illness or injury occurred and provide the incident date. Indicate whether you notified Kaiser at that time and detail any emergency care received.
Complete any additional sections regarding work-related injuries or accidents if applicable. Be sure to attach all original bills as required before submitting.

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