Kaiser Permanente Northwest Treatment Extension Request (TER to KP Direct Referrals)

Clear Form
Kaiser Permanente Northwest
Treatment Extension Request
(TER to KP Direct Referrals)
Referring Kaiser Clinician:
Patient Name:
Treating CHP Practitioner:
Phone:
Kaiser I.D. #:
Fax:
Initial Referral:
Acupuncture
# Visits Authorized
Authorization #:
Chiropractic
Naturopathic Medicine
Dates of referral:
to
# of Authorized Treatments Used:
Initial complaints:
Initial objective findings:
Diagnosis (must relate to original referral):
Treatment (including number, modalities, exercises, patient education, etc.):
Response to treatment:
Current complaints:
Current objective findings:
# of additional treatments requested:
Expected outcome/prognosis:
Signature
Time period from:
to
Date
Please complete this form, typed with standard font/typeface. Forward to the Kaiser Permanente
Community Medicine Integration Center via fax 503-813-2286 or e-mail to [email protected]
Questions about referrals should be directed to 503-813-3437 or 866-813-2437.
Revised 12/2010