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How do I fill this out?
To fill out this form, start by entering the patient's information at the top. Next, provide details about the services requested and the referring physician. Finally, ensure all required signatures are obtained before submission.
How to fill out the Kaiser Permanente Authorization Request Form?
1
Begin by entering the patient’s name and contact information.
2
Select the service type and provide diagnosis codes and descriptions.
3
Fill out the referring physician’s details including contact information.
4
Sign the form and ensure any necessary attachments are included.
5
Submit the form via fax or mail to the appropriate department.
Who needs the Kaiser Permanente Authorization Request Form?
1
Patients requiring referrals to specialists need this form.
2
Clinicians requesting prior authorization for procedures use this form.
3
Insurance representatives need this document for processing requests.
4
Healthcare facilities submitting referrals utilize this form.
5
Administrators managing patient care coordination require this document.
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What are the instructions for submitting this form?
To submit this form, fax it to Kaiser Moanalua Specialty Department at (808) 432-7380 or the Kaiser Authorization Department at (808) 432-5691. You may also mail it to Kaiser Foundation Health Plan, Inc., Hawaii Claims Administration, P.O. Box 378021, Denver, CO 80237. Make sure to provide all required information and follow up if you do not receive confirmation.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure all requests are submitted by March 1 for timely processing. For 2025, check for any changes in submission deadlines outlined by Kaiser Permanente. Always keep track of important submission dates to avoid delays in care authorization.
What is the purpose of this form?
The purpose of this form is to document and initiate the authorization process for patient referrals within the Kaiser Permanente network. It ensures that all necessary information is collected to assess the appropriateness of requested services. Proper completion and submission of this form helps facilitate timely access to healthcare services.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient requesting services.
- 2. Date of Birth: The patient's date of birth for identification.
- 3. Kaiser Medical Record #: The unique medical record number assigned to the patient.
- 4. Diagnosis Code: ICD-10 codes describing the patient's diagnosis.
- 5. Services Requested: Details on the specific services, procedures, or referrals needed.
What happens if I fail to submit this form?
Failing to submit this form can lead to delays in receiving necessary medical services. It may result in missed opportunities for treatment or specialist consultations and could affect your health outcomes. Ensure timely submission to avoid complications.
- Delayed Care: Patients may experience delays in receiving needed care.
- Increased Costs: Failure to authorize in time could lead to out-of-pocket expenses.
- Continuity of Care: Lack of authorization can disrupt continuous patient management.
How do I know when to use this form?
- 1. Specialist Referrals: Used to request referrals for specialists for patient care.
- 2. Procedure Authorizations: Necessary for obtaining approval for medical procedures.
- 3. Treatment Requests: Utilized for requesting authorization for specific treatments.
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What type of information do I need to fill out?
You need to provide patient information, diagnosis codes, and signatures.
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You can easily edit your inputs anytime before downloading.
Who should I contact if I have questions?
Contact the appropriate department listed on the form for any queries.
Are there instructions for submission?
Yes, details for submission are included within the form instructions.
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