Community providers use this Kaiser Permanente Washington fax form to request referral or authorization review from KP Review Services when sending a member to a specialist, facility or for equipment. A clinician meets it when referring a Kaiser Permanente Washington member for a service needing approval. Routine requests are processed within 5 days unless more information is needed.
The requesting community provider or office completes every field: requestor, member, referring provider and clinic, referred-to provider, facility, diagnosis and procedure codes and place of service. The urgent attestation is signed only when the request is urgent.
Download the current version from the source each time; forms change without notice.
Request for Authorization Fax Form
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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Routine requests are processed within 5 days unless more information is required, in which case KP Review Services contacts the requestor at the phone number given. Urgent requests, signed with the attestation, often require processing within one calendar day.
The referred-to physician's name and specialty, the clinic or organization's name, address, tax ID or NPI, phone and fax, plus the facility or hospital name, address, phone and fax if one is involved. The place of service is marked as office, ASC, hospital outpatient, inpatient, home or other.