Provider update forms

If you hold an active contract with Kaiser Permanente to provide outpatient mental health and substance use disorder services to Kaiser members and need to make updates to your practice demographics, please contact Magellan Healthcare at www.MagellanProvider.com and update your practice information via their online Provider Data Change Form. Refer to your welcome letter from Magellan for your username and password.

For practice changes
HR133 Demographic Change Form

This information will not be reviewed and will be loaded exactly as submitted.

• Practitioner Name Change – individual professional license name change
• Care Site Name Change - the name of your clinic
• Care Site Address change - Clinic address
• Care Site Phone/Fax number changes - appointment scheduling

HR133 – Per the federal Consolidated Appropriations Act, any of the items listed above must be loaded into our systems within 2 business days.

For organization and billing changes
2022 Standard Demographic Change Form

Changes to these data elements are subject to our standard turn-around times.

• Tax ID Changes – new W-9 required
• Tax ID Address Changes – new W-9 required
• Remit/Bill To Address Changes
• Remit NPI Changes
• General Mailing Address Changes

If you are enrolled in Electronic Funds Transfer you must also notify InstaMed of Billing NPI and Tax ID changes
Email: support@instamed.com
Phone: 1-877-833-6821

Individual practitioner term form

• Please ensure that prior to submission, verification is done to clarify whether a practitioner is being termed entirely from the organization/tax ID or only from a care site/clinic(s).
• Primary care practitioner terminations will require the name of the practitioner within the clinic/organization to whom the patient panel will be transferred to enable us to complete the panel transfer in our systems.
• If the practitioner is the only practitioner at the care site, your care site will not be displayed on the provider directory until another practitioner has been credentialed and added to your contract.

Delegated Organizations/Providers:
If your clinic is listed below, please contact your credentialing specialist to make these changes. We will not term the practitioner, as we must follow the standardized process of roster notification.

• Apple Physical Therapy (ATI)
• Children's University Medical Group
• Evergreen Health
• Franciscan Medical Group/Franciscan Health Systems
• Ginger IO
• Harborview Medical Center
• Kadlec Regional Medical Center
• Kootenai Health
• Magellan**
• MATRIX Medical Network
• Memorial Physicians, PLLC (dba Yakima Valley Memorial Hospital)
• MultiCare Health System
• Northwest Rehab Alliance (NWRA)
• PacMed Clinics
• PeaceHealth Medical Group
• Polyclinic
• Proliance Surgeons
• Providence Health & Services – Washington
• Skagit Regional Clinics/Skagit Valley Hospital
• St. Luke's Rehab Institute
• Swedish Health Services
• The Everett Clinic [TEC]
• Tivity / WholeHealth Networks, Inc.*
• University of Washington Physicians
• Valley Medical Center
• Virginia Mason Medical Center
• Walla Walla Clinic
• Western Washington Medical Group
• Yakima Valley Farm Workers

ATTENTION: You will be required to confirm an application has been attested to on HP/Provider Source/Medversant or CAQH AND all information is current prior to submission

Individual practitioner add form

Note: Do not submit for new contract requests

If you do not know if you are directly contracted with Kaiser Permanente, please reach out to your organization’s contracting department. Unsolicited requests may be declined if there is no business need.

We have limited needs within our network for new contracts. Please review the following page: Contracting with Kaiser Permanente