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.

 

ALERT: If you provide alternative and complementary medicine (i.e. chiropractic, massage therapy, acupuncture, naturopathy, etc.),


Please contact Tivity for any demographic changes at Practitioner.updates@tivityhealth.com. Kaiser Foundation Health Plan of Washington / Kaiser Foundation Health Plan of Washington Options, Inc can only make changes received from Tivity since they manage demographic details. Thank you!

 

If checked, STOP and complete the HDO PIF application.

 
 
  • Practitioners Joining Contracted Entity: Practitioner associated with an organization tax ID contracted directly with KFHPWA / KFHPWAO
  • New Contract: If your contract is held by Choice/First Health, that is considered not contracted directly with Kaiser Permanente. If you are a WholeHealth (Tivity) alternative medicine provider, please work with Whole Health Networks on contracting and credentialing activities. New group or solo practitioner tax ID requesting contract with KFHPWA / KFHPWAO
  • Practitioners Pending new Contract: Associated practitioners under new group Tax ID requesting contract with KFHPWA / KFHWAO
 
 

What age ranges are treated within your practice? Please select all age ranges that apply.

 
 
 

CAQH Credentialing Application

A complete and current application is required in CAQH in order to be considered for credentialing with Kaiser Foundation Health Plan of Washington. If there is not a complete, accurate application attested within the past 180 days available in CAQH, I understand that my application will be automatically rejected without further communication.

 
 
 
 

If your Tax ID is your social Security #, please enter 000000000.

 

Individual Practitioner Information

 
 
 
 
 
 
 
 
 
 

Do you provide Gender Affirming Services according to the latest Standards of Care published by the World Professional Association of Transgender Health (WPATH)? Expectations include:

Patients can anticipate a safe and supportive therapy tailored to individuals of all gender identities. Including:

  • Exploring one's gender incongruence/identity.
  • Working towards understanding and affirming one's gender.

For those seeking Gender Affirming Medical Intervention (GAMI), patients can expect:

  •  Support in exploring and understanding gender-affirming medical goals.
  • Guidance and psychoeducation around various GAMI interventions options allowing you space to explore potential benefits, risks, and outcomes.
  • Availability for ongoing mental health support before, during, and after medical interventions to ensure holistic care and well-being.
  • Provide documentation (WPATH) letters that are in alignment with WPATH SOC 8 and KPWA Clinical Review Criteria Gender Affirming Surgeries
 
 

Examples: Gender Health, Child and Adolescent Mental Health Care, Substance Abuse, Childhood Developmental Disorders, Dementia, etc.

 
 

As a matter of policy and as a part of our values, we keep records and perform certain analyses of our provider network pool by race, ethnicity and language. Your response will allow us to better meet member needs by allowing us to compare our provider network to the communities we serve.

 
 
 
 
 
 

Definition of "culturally congruent care": Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

 
 

Does your organization collect demographic data for patients served?

 
 
 

You may find this information on https://nppes.cms.hhs.gov/webhelp/nppeshelp/TAXONOMY%20PAGE.html

 
 
 
 
 
 
 
 
 
 
 

Contracting Information

 
 
 
 
 
 
 
 
 
Phone
 
 
 

Billing / Remit to Information

 
 
 
 
 
 
 
 
Phone
 
 

Credentialing Information

 
 
 

Practice Demographics

 
 

If you need to type in a name that is not in the dropdown, type it in and hit the TAB key.

 
 
 
 
 
 
Phone
 
Phone
 
 
 
 
 

Secondary Care Site, if applicable. If not applicable, leave blank.

 
 
 
 
 
 
 
 
Phone
 
Phone
 
 
 

Please take a moment to verify your submission fields. Please pay special attention to the practitioner name fields. There have been many instances where the browsers are Auto-Filling names which causes a mis-match of NPI and Practitioner Names. Thank you for taking the time. Mark the checkbox to verify.

 

Additional Documents

Please upload your signed Disclosure Statement, a W9 if this is a new contract and any other information necessary. No action will be taken until all documents are received. If a W9 or Disclosure is not available to you right now, send to KPWA.provider-Services@kp.org and we will add them to this form. If you have any changes to this form after submission, you can email this same email and we will send you an Update Request so you can change this form. You do not have to submit the form again.


(You may upload up to 10 documents.)

 
Drop your files here