Behavioral Health Provider Information Form (PIF)
PLEASE VERIFY THE ACCURACY OF YOUR DATA PRIOR TO SUBMISSION. IF THE INFORMATION IS INACCURATE, WE CANNOT PROCESS THE REQUEST. Most fields are MANDATORY; if not applicable, please enter N/A.
For all fields, KFHPWA refers to Kaiser Permanente of Washington and KFHPWAO refers to Kaiser Foundation Health Plan of Washington Options, Inc.