Fax form community providers use to request authorization/referral review from Kaiser Permanente Washington.
- Completed by
- Requesting community provider
- Issued by
- Kaiser Permanente Washington
- Format
- Fillable PDF
- Language
- English
Washington Universal SUD Residential Authorization Form
Washington requires health carriers to accept a universal format for authorization and reauthorization of inpatient or residential substance use disorder treatment, adopted under chapter 366, Laws of 2024 and WAC 284-43-2070. A SUD treatment facility or clinician meets it when admitting a member to withdrawal management or residential care. The two-page form carries administrative details only, from ASAM level of care to diagnosis.
Who completes it
The requesting SUD treatment facility or provider completes all seven sections: submission information, the authorization request, member information, utilization management contact, requesting provider, servicing provider and primary diagnosis.
Submitting and payment
- How to submit it
- Send it to the carrier following the submission instructions the carrier adds to its own copy of the form.
Good to know
- Mark initial authorization or reauthorization and withdrawal management or non-withdrawal management, with the admission date and dates requested.
- The level of care is entered by ASAM level, with the proposed HCPCS or CPT code that corresponds to it and any current authorization number.
- Carriers may add only a logo, up to five sentences of submission instructions and a HIPAA disclaimer; they may not otherwise change the form.
- The rule took effect January 19, 2026, and new or updated versions must be posted on the Insurance Commissioner's website 30 days before taking effect.
Get the official form
Download the current version from the source each time; forms change without notice.
Basic administrative information for authorization/reauthorization residential substance use disorder treatment
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Do Washington carriers have to accept the universal SUD authorization form?
Yes. WAC 284-43-2070 requires carriers to accept the universal format for authorization and reauthorization of inpatient or residential substance use disorder treatment services. Apple Health managed care plans also accept it. The form is posted on the Office of the Insurance Commissioner's website.
Does the Washington universal SUD form include clinical information?
No. Its title calls it basic administrative information: request type, ASAM level of care, codes, member details, utilization management contact, providers and the primary diagnosis. It has no clinical sections, so clinical information is not part of this form.