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The document is a 'Statement of Authorized Representative' form from Kaiser Foundation Health Plan, Inc. It allows members to authorize another party to file complaints, grievances, or appeals on their behalf regarding care quality or service coverage. The form includes sections for personal information, authorization details for disclosing Protected Health Information (PHI), and revocation rights. It emphasizes that providing this authorization is voluntary and can be revoked at any time.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I download Kaiser records?

Under Member support, click Medical Information Requests. You will be directed to a page titled Records, forms and certifications. Find what you need in the list of links at the top of the page: Click Medical records to request your electronic medical record.

What is a 1095-B form used for?

Form 1095-B is used to report certain information to the IRS and to taxpayers about individuals who are covered by minimum essential coverage and therefore are not liable for the individual shared responsibility payment.

Does Kaiser send out 1095 forms?

Employees who have Kaiser insurance will receive the 1095 directly from Kaiser. 1095 forms will be available online through the members Kaiser Permanente account. To request a paper copy, please contact member services at 877.514. 5114.

Why does Kaiser ask for a social security number?

Kaiser Permanente has been required to report to the Internal Revenue Service (IRS) your enrollment in certain Kaiser Permanente health plans. * For this we need your Social Security number (SSN) or other Tax Identification Number (TIN) and those of your family members covered under your plan.

What number is 833 574 2273?

Get medical advice and care guidance in the moment from a Kaiser Permanente provider at 1-833-KP4CARE (1-833-574-2273) or 711 (TTY). Same-day appointments are often available. Sign in to kp.org anytime, or call us to schedule a visit. Get quick online care for minor health problems.

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How do I get a copy of my 1095 health insurance form?

How to find your 1095-A online Log into your Marketplace account. Under Your applications, select your 2024 application not your 2025 application. Select Tax Forms. Download all 1095-As.

How do I request an itemized bill from Kaiser?

Itemized billing records You can request an itemized summary of out-of-pocket costs youve paid for health care by following these steps: Fill out an Authorization to Use and Disclose Protected Health Information form (PDF) Send a secure message to your provider by clicking Send a message in MyChart.

Who sends me my 1095-A form?

Form 1095-A, Health Insurance Marketplace Statement, is provided by the Marketplace to individuals who enrolled or who have enrolled a family member in health coverage through the Marketplace. Form 1095-B, Health Coverage, is provided by insurance companies and other coverage providers.