Kaiser Referral Authorization Form
Kaiser Referral Details:
Referral Priority
*
Referring Provider
*
Referral Provider NPI
*
Medical Record Number
*
Patient Details:
Patient Legal Name
*
First Name
Last Name
Patient Preferred Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Please Select
Male
Female
Other
Member Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member Phone Number
*
Format: (000) 000-0000.
Member E-mail
example@example.com
Language Assistance Needed
Primary Language Spoken
*
Please Select
English
Spanish
Coverage Type
Diagnosis ICD
Referral Authorization Number
*
Referral Authorization From
*
-
Month
-
Day
Year
Date
Referral Authorization To
*
-
Month
-
Day
Year
Date
Estimated Member Liability
CMS Place of Service Code
*
Place of Service Location
Referral Authorization Information
Provider Name/Group/Facility
Authorized Evaluation Type
*
Please Select
Neuropsychological
Developmental
Psychodiagnostic
KP Clinic Contact Name
KP Clinic Contact Phone/Fax
KP Clinic Contact Email
Fax Report To
Clear Reason for Referral with relevant diagnostic information
CPT Code 1
*
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 1
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 2
*
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 2
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 3
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 3
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 4
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 4
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 5
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 5
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 6
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 6
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 7
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 7
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 8
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 8
Please Select
1
2
3
4
5
6
7
8
9
10
11
CPT Code 9
Please Select
96116
96121
96132
96133
96146
90791
96112
96113
96130
96131
96136
96137
96138
96139
Units 9
Please Select
1
2
3
4
5
6
7
8
9
10
11
Medical Record File Upload If Included w/ Referral)
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