Documents and Forms

Links to important forms and documents.

Provider Options by Location:

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

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.

Quick Documents

Formularies

Out-of-Area PPO Formulary

Specialty Drugs List

Pharmacy Claim Form

Precertification Lists

VA OOA-PPO Precertification List

MD OOA-PPO Precertification List

D.C. OOA-PPO Precertification List

Other Documents and Forms

Precertification Request Form

Medical Claim Form

Nominate a PHCS and/or MultiPlan Provider

Member Care Transition Form

Member Coverage Documents

Out-of-Area PPO Plan Reference Guide

Out-of-Area PPO Overview Flyer for Members

Out-of-Area PPO Information for Physicians

PHCS Provider Flyer

Your Rights and Protection Against Surprise Medical Bills – Maryland

Your Rights and Protection Against Surprise Medical Bills – District of Columbia

Your Rights and Protection Against Surprise Medical Bills – Virginia

Preparing for your Appointment

KPIC Notice of Language Assistance and Non-Discrimination

Maryland MHPAEA Summary Form

*Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the In-Network PPO Tier (Option 1) and Out-of-Network Tier (Option 2).