Documents and Forms

Links to important forms and documents:

Member Resources:

Provider Directories

Kaiser Permanente Providers and Locations – Northern California

Kaiser Permanente Providers and Locations – Southern California

Provider Options by Location:

In Kaiser Permanente States: The PHCS Network for KPIC provides access to care in the Kaiser Permanente states of CA, CO, GA, HI, MD, OR, VA, WA, and DC.

In Non-Kaiser Permanente States: The CignaPPONetwork* only provides access to care in non-Kaiser Permanente states

*Disclaimer: The Cigna PPO Network refers to providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.

POS Pharmacy Locator Tool

Drug Formulary

Kaiser Permanente Drug Formulary

Formulary with Specialty Drug Tier – MedImpact Pharmacy (Non-grandfathered)

Standard Formulary – MedImpact Pharmacy (Grandfathered)

MedImpact Immunization List for 2022

Claim forms

Medical Claim Form

Emergency Medical Services Claim Form

MedImpact Prescription Drug Claim Form

Other documents and forms

POS Member Handbook

POS Plan Overview

POS Plan Overview, en Espanol

Filling Prescriptions at MedImpact Retail Pharmacies

Filling Prescriptions at MedImpact Retail Pharmacies, en Espanol

MedImpact Standard Commercial Guidelines

Permanente Advantage – Precertification and Care Management

Permanente Advantage – Precertification and Care Management, en Espanol

Permanente Advantage Precertification Request Form

HIPAA Authorization Form

Member Care Transition Form

Member Care Transition Form, en Espanol

Nominate a PHCS Provider

Preparing for your Appointment

Preparing for your Appointment, en Espanol

Confidential Communication Request Form (English)

Confidential Communication Revocation Form (English)

Your Rights and Protection Against Surprise Medical Bills