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  • California DE4 Withholding
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Enrollment Application or Change Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Federal W-4 Withholding
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Meritain Health Claim Form (for services rendered on or after January 1, 2014)
    Submit to Meritain Health with appropriate receipts (see form for details)

  • Retiree Health Coverage Cancellation Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Life Insurance Beneficiary Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Retiree Life Insurance Cancellation Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Senior Advantage Election Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Senior Advantage Disenrollment Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Special Dependent Enrollment/Deletion Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Special Dependent Physician Affidavit
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Tapered Life Insurance Cancellation Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Tapered Life Insurance Coverage Reduction Form
    Submit to PHR Shared Services at 626-628-3789 (fax) or PHRSharedServices@kp.org

  • Travel/Emergency Visit Claim Form
    Mail to Kaiser Foundation Health Plan with appropriate bills (see form for details)