Kaiser Permanente Patient Referral

Kaiser Permanente Patient Referral
Patient's details
Patient's Name*

First NameLast Name
Patient Kaiser Medi-Cal ID: *
Patient's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Date of Birth*
Patient's email
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
ICD-10 Code(s) (Ailments) (if you know them)
Important Note: To qualify for Personal Care and Homemaker services through Kaiser Permanente Medi-cal, you must begin the enrollment process for the In-Home Supportive Services (IHSS) program. If you need assistance with this process, please call Kaiser Permanente Member Services at 1-855-839-7613. If you are already receiving IHSS, please indicate how many hours per month you were approved for.*
Tell us about the patient's current medical conditions.*
Should be Empty: