National Claims Administration NCR

Kaiser Foundation Health Plan, INC

PO Box 629028 Accrual toward deductibles and out-of-pocket
El Dorado Hills, CA 95762-9028 maximums
To see how close you are to reaching your
deductibles, if any, and out-of-pocket maximums,
use our online Out-of-Pocket Summary tool at
kp.org/outofpocket or call Member Services. We
will provide you with accrual balance information
Shruti Modi for every month that you receive Services until
396 ANO NUEVO AVE APT 212 you reach your individual out-of-pocket maximums
SUNNYVALE, CA 94085-1615 or your Family reaches the Family out-of-pocket
maximums.

We will provide accrual balance information by

mail unless you have opted to receive notices
electronically. You can change your document
delivery preferences at any time at kp.org or
by calling Member Services at 1-800-390-3510
Weekdays 7:00AM – 7:00PM (Pacific Time).

Track your care March 31, 2024

Medical record number: 0016736622 Group identification: 000039717*0000

Plan type: HMO - HMO COMMERCIAL- Account Holder Name and Identification: JIMIT MODI,
HMO 110016736619
Plan year: 01/01/2024 through 12/31/2024 Member Relationship to Subscriber: Spouse

Letter of Accruals for Shruti Modi

The deductible (if applicable) and out-of-pocket summary you receive is tailored to your situation. It takes into account
what's covered by your health plan benefits, and it shows how much you've spent so far for care.

Here’s how close you are to reaching your deductibles and out-of-pocket maximums.

Out-of-pocket maximum - Year to date

Shruti Modi

$6.44
Tier 1 $0 $2000.00

Family totals

$132.76
Tier 1 $0 $5000.00
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