Kaiser Permanente

For more than 60 years, Kaiser Permanente has proved quality health care. We’re dedicated to improving the health of our members and the communities we serve, by creating safe, healthy environments and providing care and coverage for all.

 Provider Finder

Form Name Effective Date Download Form
Electronic Transfer for Initial Payment Form
01/01/2017 Download
New Group Enrollment Checklist
01/01/2017 Download
Employee Termination Transfer Form
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New Group Application
01/01/2017 Download
Group Size Attestation Form
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Group Term Request
01/01/2017 Download
New Employee Eligibility
01/01/2017 Download
Online Account Services User ID Request
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Renewal Date Change Request
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Sole Proprietor Partner Corporate Officer Statement
01/01/2017 Download
Validation Matrix
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Form Name Effective Date Download Form
Claim Form - Emergency Services
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Employee Enrollment
01/01/2017 Download
Employee Enrollment - Spanish
01/01/2017 Download
Employee/ Dependent Change
01/01/2017 Download
Employee/ Dependent Change - Spanish
01/01/2017 Download
Declination of Coverage
01/01/2017 Download
Declination of Coverage - Spanish
01/01/2017 Download
Employee HIPAA Form
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Form Name Effective Date Download Form
Medical HMO
Platinum 90 HMO 0 10 with Child Dental ALT – Infertility
07/01/2017 Summary SBC
Platinum 90 HMO 0 10 with Child Dental ALT – Infertility
01/01/2017 Summary SBC
Platinum 90 HMO 0 10 with Child Dental ALT
07/01/2017 Summary SBC
Platinum 90 HMO 0 10 with Child Dental ALT
01/01/2017 Summary SBC
Platinum 90 HMO 0 15 with Child Dental – Infertility
07/01/2017 Summary SBC
Platinum 90 HMO 0 15 with Child Dental – Infertility
01/01/2017 Summary SBC
Platinum 90 HMO 0 15 with Child Dental
07/01/2017 Summary SBC
Platinum 90 HMO 0 15 with Child Dental
01/01/2017 Summary SBC
Gold 80 HMO 0 30 with Child Dental – Infertility
07/01/2017 Summary SBC
Gold 80 HMO 0 30 with Child Dental – Infertility
01/01/2017 Summary SBC
Gold 80 HMO 0 30 with Child Dental
07/01/2017 Summary SBC
Gold 80 HMO 0 30 with Child Dental
01/01/2017 Summary SBC
Gold 80 HMO 500 35 with Child Dental ALT – Infertility
07/01/2017 Summary SBC
Gold 80 HMO 500 35 with Child Dental ALT – Infertility
01/01/2017 Summary SBC
Gold 80 HMO 500 35 with Child Dental ALT
07/01/2017 Summary SBC
Gold 80 HMO 500 35 with Child Dental ALT
01/01/2017 Summary SBC
Gold 80 HRA HMO 2000 30 with Child Dental – Infertility
07/01/2017 Summary SBC
Gold 80 HRA HMO 2000 30 with Child Dental – Infertility
01/01/2017 Summary SBC
Gold 80 HRA HMO 2000 30 with Child Dental
07/01/2017 Summary SBC
Gold 80 HRA HMO 2000 30 with Child Dental
01/01/2017 Summary SBC
Silver 70 HDHP HMO 2000 20% with Child Dental - Infertility
07/01/2017 Summary SBC
Silver 70 HDHP HMO 2000 20% with Child Dental - Infertility
01/01/2017 Summary SBC
Silver 70 HDHP HMO 2000 20% with Child Dental
07/01/2017 Summary SBC
Silver 70 HDHP HMO 2000 20% with Child Dental
01/01/2017 Summary SBC
Silver 70 HMO 1000 50 with Child Dental ALT – Infertility
07/01/2017 Summary SBC
Silver 70 HMO 1000 50 with Child Dental ALT – Infertility
01/01/2017 Summary SBC
Silver 70 HMO 1000 50 with Child Dental ALT
07/01/2017 Summary SBC
Silver 70 HMO 1000 50 with Child Dental ALT
01/01/2017 Summary SBC
Silver 70 HMO 2000 45 with Child Dental – Infertility
07/01/2017 Summary SBC
Silver 70 HMO 2000 45 with Child Dental – Infertility
01/01/2017 Summary SBC
Silver 70 HMO 2000 45 with Child Dental
07/01/2017 Summary SBC
Silver 70 HMO 2000 45 with Child Dental
01/01/2017 Summary SBC
Bronze 60 HDHP HMO 4800 40% with Child Dental – Infertility
07/01/2017 Summary SBC
Bronze 60 HDHP HMO 4800 40% with Child Dental – Infertility
01/01/2017 Summary SBC
Bronze 60 HDHP HMO 4800 40% with Child Dental
07/01/2017 Summary SBC
Bronze 60 HDHP HMO 4800 40% with Child Dental
01/01/2017 Summary SBC
Bronze 60 HMO 6300 75 with Child Dental – Infertility
07/01/2017 Summary SBC
Bronze 60 HMO 6300 75 with Child Dental – Infertility
01/01/2017 Summary SBC
Bronze 60 HMO 6300 75 with Child Dental
07/01/2017 Summary SBC
Bronze 60 HMO 6300 75 with Child Dental
01/01/2017 Summary SBC
Medical PPO
Platinum 90 PPO 0 15 with Child Dental
07/01/2017 Summary SBC
Platinum 90 PPO 0 15 with Child Dental
01/01/2017 Summary SBC
Gold 80 PPO 0 30 with Child Dental
07/01/2017 Summary SBC
Gold 80 PPO 0 30 with Child Dental
01/01/2017 Summary SBC
Silver 70 PPO 2000 45 with Child Dental
07/01/2017 Summary SBC
Silver 70 PPO 2000 45 with Child Dental
01/01/2017 Summary SBC
Bronze 60 PPO 6300 75 with Child Dental
07/01/2017 Summary SBC
Bronze 60 PPO 6300 75 with Child Dental
01/01/2017 Summary SBC
Form Name Effective Date Download Form
CA Travel Brochure
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Carryover Guidelines
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DME Benefits Flyer
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Expanding Hospital
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General Travel Information
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Health Payment Accounts
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HRA Pay to Provider
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HealthCare Reform Resource Guide National
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Kaiser 2017 Sample Fee List
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Mail Order Flyer
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Medicare Creditable Coverage
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Minimum Essential Coverage Employer Reporting Fact Sheet
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Minimum Essential Coverage
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Mobile Health Vehicle - SD Trifold
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Online Resources Flyer
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Preventative Services
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Q&A Post Enrollment
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Quick Reference Guide - Brokers
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Quick Reference Guide - Employers
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Ready Set Thrive
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Recertification Information
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Resource Guide
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San Diego Map
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San Diego Provider Directory
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San Diego Telephone Appointment
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SD Health Everywhere
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Target Clinic - SD
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Underwriting Guidelines
01/01/2017 Download
Urgent Care SCAL - English
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Urgent Care SCAL - Spanish
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We Are Here For You
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Form Name Effective Date Download Form
Contact Sheet
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