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Mid-Atlantic Provider website forms
Interested in joining the Kaiser Permanente network of physicians?

Our forms directory helps you save time. You can download forms at your convenience instead of having to call us to request them.

Organization/facility credentialing/re-credentialing application

Mid-Atlantic Provider website forms

With access to the secure provider website, users can view patient coverage, benefit and copay information, and check the status of referral requests online.  Practitioners have access to medical information obtained from patient visits with Kaiser Permanente and a wide range of online reference tools.

Provider Demographic Request*
Please submit all demographic changes in writing on company letterhead to the Provider Relations department at 855-414-2623 or email:
*Note:  Delegated providers should not use this form.  Please contact your delegated representative for demographic updates.

Request for electronic funds transfer (EFT)*
This form allows a provider to request for electronic funds transfer (EFT) for claims payment. Please follow the instructions on the application.

Request an on-site orientation*
This form lets you request a formal Kaiser Permanente on-site orientation for your practice. The form must be completed and faxed to Provider Relations at

Request a provider manual*
Use this form to request that a Kaiser Permanente provider manual be sent to you in the mail.

External referral and authorization form*
View an example of our new Kaiser Permanente referral form.

Uniform consultation referral form*
Use this form to request a referral.

Applied Behavioral Analysis (ABA) Therapy Guide* Use this form to help you submit your ABA therapy treatment plan.

Provider Payment Dispute Resolution Form*
Use this form to file an appeal or level of payment dispute.

Organization/facility credentialing/re-credentialing application*
Use this form to submit for credentialing/re-credentialing. This form should not be submitted in lieu of an application if you are a new provider interested in joining the Kaiser Permanente network. If you are interested in joining the network, please choose the correct form in the section below.

If your provider type is indicated below, please do not apply with the above applications for participation. Please contact the numbers below for further information on joining the network.

Chiropractic Providers:
Please contact Optum Health Care Solutions, Inc. (OCS) 1-800-873-4575 for further information about network participation.

Dental Providers:
Please contact Dominion Dental Services, Inc. 1-855-733-7524 for further information about network participation.

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Interested in joining the Kaiser Permanente network?

We only accept applications for providers that provide services in the Washington, DC, Maryland, and Northern Virginia areas.

The counties included in our service areas are:

DC/SM Counties: Calvert (partial), Charles (partial), Frederick, Montgomery, Prince George’s, Washington, DC

Baltimore Counties: Anne Arundel, Baltimore, Baltimore City, Carroll, Harford, Howard

Northern VA Counties: Alexandria City, Arlington, Caroline (partial), Culpeper (partial), Fairfax, Fairfax City, Falls Church City, Fauquier (partial), Fredericksburg City, Hanover (partial), King George (partial), Loudoun, Louisa (partial), Manassas City, Manassas Park City, Orange (partial), Prince Wiliam, Spotsylvania, Stafford, Westmoreland (partial)

For health care practitioners ONLY
Please complete all of the following:

For institutions and providers of ancillary services ONLY
Please complete all of the following:

For Applied Behavioral Analyst (ABA) providers ONLY
Please complete all of the following:

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