Inform us of your practice changes

Choose the appropriate form below

*Alternative medicine providers
Chiropractors, Naturopaths, Massage Therapists and Acupuncturists		Email provider.updates@tivityhealth.com.
**Mental health providers

ONLY 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.
All other mental health provider updates (inpatient, IOP, PHP, RTC, TMS, ABA) should use the forms below.

*Exception: Tax ID and Tax ID Name Changes please see steps below as these change impact contract records and need to be submitted via our process below in addition to updating Magellan.

Practice, organization and billing changes

Tax Id Name and/ or Tax ID Changes are contracting updates:

Submit a demographic information form to Kaiser Permanente using this link: Practice, organization and billing changes

Important: Payment may be impacted by these types of changes. A 90 day notice is required to avoid reprocessing and to ensure claims impact is mitigated.

  • If we do not receive notice of your change within the 90-day required period, your change may not be reflected in our systems
  • Bills submitted during the 90-day notice period may be denied.
  • Tax ID Name changes require a signed contract amendment and a system update
  • Tax ID changes require a system update

There are two types of changes that may require additional documentation:

  • Acquisition – An acquisition is when an entity purchases a company or multiple companies. Requires advance notice and the bill of sale/acquisition contract signed by both parties to update the contract.
  • Assignment – An assignment is when an entity transfers the rights and obligations under its current contract with Kaiser Permanente to a new owner. If the new contract owner does not accept the existing contract terms, we cannot issue an assignment. A W9 is required to update the contract.

Billing NPI changes:
Change from Type I to Type II NPI and/or Solo to Group

This is not a contract action UNLESS the provider is changing their Tax ID and/or Changing their Tax ID Name (see above)

  • Solo providers updating practice type to a group:

Terming a practitioner

Individual practitioner term form
Term a practitioner from a care site and/or from an organization/TIN

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

Contract termination
Active contracts only

Full contract termination requires a formal notification per your contract notification terms. Please submit the Contract Termination form and upload a letter of termination to initiate the process.

If your contract is held by WholeHealth (Tivity) or First Choice/First Health, notify your contracting entity directly.

Adding an individual practitioner

Individual practitioner add form
Active contracts only

Active contracts: If you do not know if you are directly contracted with Kaiser Permanente, please reach out to your organization’s contracting department. Unsolicited requests will be declined if there is no active contract

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