Kaiser Referral Request Form PDF Details

Are you in need of a referral for medical services through Kaiser Permanente? If so, then look no further - the Kaiser Referral Request Form is specifically designed to help those who have chosen to go through Kaiser Permanente receive specialized care from other providers. Whether your condition requires additional treatments not available at a Kaiser facility or you’d like your doctor to refer you to another specialist within the network, this form makes obtaining a referral simple and convenient. Read on for more information about how it works and why it's important for anyone with a Kaiser plan.

QuestionAnswer
Form NameKaiser Referral Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescolorado kaiser authorization form, colorado kaiser form, kaiser referral form, kaiser permanente colorado 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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