Kaiser Referral Request Form PDF Details

Navigating healthcare protocols can often feel like a maze, but tools like the Kaiser Permanente Colorado Prior Authorization Request Form are designed to streamline processes for both healthcare providers and patients. This form, crucial for facilitating various healthcare services within Kaiser Permanente's network, especially in Colorado, carries significant importance. Required for both routine and urgent referrals, it ensures that patients receive the necessary pre-approval for medical procedures or consultations they may need. With dedicated fax numbers for different regions, such as Southern Colorado and Denver/Northern Colorado, and a specific line for preauthorization questions, the form outlines a structured pathway for submitting requests. Essential details such as the patient's Kaiser Permanente number, personal information, the referring and requested physicians' details, preliminary diagnosis, ICD codes, and the demanded service or procedure with the expected date are all integrated into the form to expedite the authorization process. This meticulous compilation of data underlines the importance of including relevant clinical information to support the request, highlighting the balance between bureaucratic requirement and clinical need. Furthermore, it reminds users to avoid abbreviations or acronyms, ensuring clarity and preventing misunderstandings that could delay patient care. Established in April 2013, this form represents a critical interface between healthcare bureaucracy and patient care, underpinning the logistical framework necessary for efficient healthcare delivery within the Kaiser Permanente ecosystem.

QuestionAnswer
Form NameKaiser Referral Request Form
Form Length1 pages
Fillable?Yes
Fillable fields20
Avg. time to fill out4 min 19 sec
Other nameskaiser colorado prior authorization form, kaiser authorization request form, kaiser authorization colorado, kaiser permanente pharmacy prior auth form

Form Preview Example

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Kaiser Permanente Colorado Prior Authorization Request Form

***Please use a Fax Cover Sheet when faxing to Kaiser Permanente***

Southern Colorado:

*Routine Referrals: Fax to 866-529-0934

*Urgent Referrals (Services expected to be provided within 72 hours): Fax to 866-529-0934

Denver and Northern Colorado:

*Routine Referrals: Fax to 877-685-6272

*Urgent Referrals (Services expected to be provided within 72 hours): Fax to 877-685-6272

For preauthorization questions please call: 1-877-895-2705

*Date: ____________________

*Patient KP #: __________________ *Patient Phone #: ___________________ *DOB: _____________

*Patient Last Name: ________________________ *Patient First Name: _________________________

______________________________________________________________________________________

*(Address)

*(City)

*(State)

*(Zip)

 

 

 

 

PCP: ______________________

PCP Phone #: __________________

 

 

 

 

 

 

*Please include relevant clinical information with the Prior “Authorization Request Form.”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referred By

 

 

 

Referred To / Requested Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Referring Physician:

 

*Physician:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Specialty:

 

*Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Phone

 

*Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Form Completed By:

 

*Place of Service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Preliminary Diagnosis:

 

Phone:

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*ICD Codes:

 

Inpatient

 

 

 

Outpatient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*CPT/HCPC

 

*Quantity/

 

*Procedure /

 

 

 

 

 

 

 

 

 

 

 

#of Visits

 

Description

 

 

 

 

 

 

1:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Transplant related Services

 

 

3:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Out of Service Area Prior

 

 

4:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indication for Out of Service Area Request:

5:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Expected Date of Service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax authorization request to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Required Information Please do not use abbreviations or acronyms

KH April 2013

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1. The co kaiser form usually requires specific details to be typed in. Be sure the next blank fields are completed:

Filling in segment 1 in kaiser referral form

2. Right after performing the previous section, go on to the subsequent stage and fill out the necessary details in all these fields - Referred By, Referred To Requested Service, Referring Physician Specialty Phone, Fax, Form Completed By Preliminary, ICD Codes, Transplant related Services, Out of Service Area Prior, Indication for Out of Service Area, Physician Specialty Phone, Fax, Place of Service, Phone Fax, Inpatient Outpatient, and CPTHCPC.

kaiser referral form conclusion process clarified (portion 2)

3. In this stage, review KH April, Expected Date of Service Fax, and Required Information Please do not. Each one of these will need to be filled out with highest focus on detail.

Step no. 3 of filling in kaiser referral form

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