To submit the MFA form, you have several options. You can complete it online at www.kp.org/mfa/ncal, fax it to 1-800-687-9901, mail it to Kaiser Permanente MFA Program, PO Box 30006, Walnut Creek, CA 94598, or drop it off in person at any Kaiser Permanente facility. Ensure all information is accurately filled out and all necessary documentation is included to avoid delays in processing.

For 2024 and 2025, the important dates to keep in mind are the annual federal poverty level updates released in January. It's essential to check for updates to the eligibility criteria and any changes in application deadlines each year.

The purpose of this form is to provide financial assistance to individuals facing difficulty paying for medical care at Kaiser Permanente. The MFA Program helps by offering temporary financial awards to qualified applicants based on their financial needs. By completing this form, eligible patients can receive aid for emergency or medically necessary care, ensuring they have access to the healthcare services they need during financial hardships.

• 1. Applicant Information: Collects personal details such as name, address, and contact information.
• 2. Household Income: Includes fields to report gross monthly household income and sources of income.
• 3. Medical Expenses: Requires information about out-of-pocket costs for medical care, dental care, and medication.
• 4. Supporting Documentation: Lists required documents like proof of income and medical bills to verify eligibility.

Failure to submit this form can result in the inability to receive financial assistance for medical care. This may lead to challenges in accessing necessary medical services.

• Loss of Financial Assistance: Without this form, you may not receive aid to help cover medical expenses.
• Inability to Access Medical Care: Failing to apply can prevent access to necessary healthcare services.
• Increased Financial Burden: Lack of assistance may lead to higher out-of-pocket costs for medical treatments.

• 1. Seeking Financial Aid: When you need temporary financial help to cover medical costs.
• 2. High Medical Expenses: If your out-of-pocket medical expenses exceed 10% of your gross household income.
• 3. Uninsured Patients: For those without health insurance needing assistance with medical bills.
• 4. Applying for Other Coverage: When required to apply for Medi-Cal or other public/private health programs.
• 5. Emergency Medical Care: If you need help paying for emergency or medically necessary treatments.