Documents and Forms

Links to important forms and documents:

Member Resources:

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 Cigna Healthcare PPO Network* 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.

PPO Pharmacy Locator Tool

Drug Formulary

PPO Formulary with Specialty Drug Tier – Medimpact Pharmacy (Non-Grandfathered)

PPO Standard Formulary – MedImpact Pharmacy (Grandfathered)

Claim forms

Medical Claim Form

MedImpact Prescription Drug Claim Form

Documents and forms

PPO Member Handbook

PPO Plan Overview

PPO Plan Overview, in Chinese

PPO Plan Overview, en Espanol

Kaiser Permanente Insurance Company - Small Group PPO 2024 Plain Language Filing

Kaiser Permanente Insurance Company - Large Group PPO 2024 Plain Language Filing

Walgreens Home Delivery Prescription Services

Walgreens Home Delivery Prescription Services 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

Small Group Transparency in Coverage

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

KPIC Notice of Language Assistance

KPIC Notice of Non-Discrimination