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The "NON-PLAN CARE INFORMATION - Oregon" form is used by Kaiser Permanente to document care received outside of a predetermined health plan. This form is crucial for patients who have received medical services not covered by their regular health insurance plan, particularly when treatment is rendered by providers who are not within the Kaiser network. It aims to accurately collect details such as patient information, medical services received, and circumstances requiring non-plan care, ensuring a thorough understanding of the situation that necessitated services outside of the standard coverage.
Utilization of this form is generally initiated by patients needing to report care received outside of their covered plan. Follow these steps for completion:
When filling out the "NON-PLAN CARE INFORMATION - Oregon" form, consider the following sequence to enhance efficiency:
This form plays a key role in clarifying reimbursement scenarios for healthcare outside of a standard plan, providing members with an opportunity to potentially recoup expenses. It is essential in ensuring that Kaiser Permanente has comprehensive data to make informed decisions regarding out-of-plan care requests and subsequent coverage or payment possibilities.
Oregon may have specific guidelines or exceptions with respect to out-of-plan care, particularly for coverage of emergency services or referrals. It is crucial for residents to be aware of these regulations to ensure that their form submission accounts for any state-specific nuances, particularly regarding what constitutes emergent or necessary unplanned care.
Consider a scenario where an Oregon resident traveling out of state requires emergency treatment that their local, in-network providers cannot offer. By filling out the form with exhaustive details of the incident and care provided, the patient can seek reimbursement or understand any potential limitations on coverage effectively.
This form is primarily used by Kaiser Permanente members who have sought medical treatment outside their regular provider network due to emergencies or specialized care needs. It is particularly relevant for those holding a Kaiser Permanente insurance plan in Oregon, where a detailed account of the non-plan care assists in determining coverage eligibility.


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I AUTHORIZE THE RELEASE OF ANY AND ALL. INFORMATION NECESSARY TO PROCESS THIS CLAIM INCLUDING MEDICAL AND/OR HOSPITAL RECORDS TO KAISER FOUNDATION HEALTH PLAN.
Aug 28, 2025 Passed by the Oregon Legislature as Senate Bill 619, it took effect for many businesses on July 1, 2024, and will extend to covered nonprofit