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Form 8853 Vancouver Washington: What You Should Know

If your physician files Form 2068R, it will need to be signed by you or your medical provider. Furnish a copy to your physician. Coding and documentation required to send your physician's or other providers' statements to Clark County WA: Name: Address: E-mail address: Medicare numbers or billing codes: Filing status: • Form 2068R. Who can send to: • Kaiser Permanent Washington (includes all Kaiser Permanent providers) • Clark County Medicare Services. All documents must be in PDF format. Where do I print? You must print from the computer screen (the fax option will not work) and do not use a printer. File your Form 88853 and attach a copy of the documentation to it. Attain Letter of Authorization. Oct 1, 2024 — The filing date shown here. Form 8853 for Proposers/Form 8853 for Proposers • File Forms 8853 (payable to “Kaiser Permanent Washington, Inc.”) With Kaiser Permanent. If you are a Kaiser Permanent Proposer and you receive Forms 4661, 6462, 6463, 6464, 6465, or 4855, or are a Kaiser Permanent Proposer for the same year for which you file Forms 8853, you do not receive a Form 8853 or you need to have it sent from Proposer. • Include your contact information in your Form 8853. • This file is also filed under Form 8853 for Proposers. • This is a copy of the form for the following year. Who can send to: The following medical providers can submit their Form 6465 to any of the following offices: • Clark County (includes all Kaiser Permanent providers and other health care payers) • Clark County Medicare Services • Clark County (includes all Kaiser Permanent providers and other health care payers) What is Form 88853? What you will receive: A Form 8853 for Proposers/Form 88853 for Proposers. You may need to fax your form. The fee to file for a proposed health plan (PRN) is 8.25% of your gross receipts from the plan year to determine how much the plan is likely to cost you.

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