2016 permanente claim self funded-2026

1. Click ‘Get Form’ to open the 2016 permanente claim self funded in the editor.
2. Begin by filling out the Participant Data section. Include your name, address, marital status, and contact numbers. Ensure all fields are completed for prompt processing.
3. Next, move to the Patient Data section. Enter the patient's name, date of birth, relationship to you, and any other relevant details such as whether they are a full-time student.
4. If applicable, complete the Other Coverage Data section. Indicate if the patient has other health coverage and provide necessary details about that coverage.
5. Sign the Authorization section to allow KPIC to process your claim. This is crucial for compliance and timely processing.
6. Attach itemized bills from your provider that include all required information such as dates of service and nature of expenses.
7. Finally, send the completed form along with attachments to Kaiser Permanente Insurance Company at the provided address.

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