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Get Kern Family Health Care Referral/Prior-Authorization Form

Referral/Prior-Authorization Form Phone 661/664-5083 Fax 661/664-5190 Please Check Type PLEASE PRINT Routine Urgent/Expedited Please Check Product KFHC Medi-Cal KFHC Healthy Families GHP Member Information Complete in full Patient Name Alternate Contact Information Address City State KFHC Member ID DOB Zip Daytime Phone Age CCS Eligible Condition YES Alternate ID NO CCS Open Case Facility / Provider Information Complete in full Requesting Provider Phone Fax Provider Signature Date Requested Service s ICD9 Code s CPT Code s Patient Request Allergy Cardiology Dermatology DME Endocrine ENT GE/GI General Surgery Hem/Onc Home Health Mental Health Nephrology Facility Orthopedics Neurosurgery Pain Mgmt OB/GYN Pharmacy Ophthalmology Physical Therapy Requested Provider Podiatry Rheumatology Pulmonology Urology INFORMATION BELOW MUST BE COMPLETED TO PROCESS SERVICE REQUEST Diagnosis / Clinical Problem KFHC Date Rec d Stamp Clinical History / Date of Onset To facilitate processing of request please attach clinical documentation including progress notes reports labs imaging etc. Total additional pages For Kern Family Health Care Use ONLY Approved Denied Modified Withdrawn Delayed Duplicate Request Disenrolled Auth Commentary/UM Criteria Not Met Reviewer Signature PCP AUTHORIZATION CONTINGENT UPON ELIGIBILITY ON DATE OF SERVICE Eligibility Date HIPAA Notice The information contained in this form may contain confidential and legally privileged information. It is only for the use of the individual or entity named above. If the recipient of this form is not the recipient addressed on the form you are hereby notified that any dissemination distribution or copying of the attached document s is strictly prohibited. If you have received this in error please immediately notify the sender by telephone and return the form to the sender. If the recipient of this form is not the recipient addressed on the form you are hereby notified that any dissemination distribution or copying of the attached document s is strictly prohibited* If you have received this in error please immediately notify the sender by telephone and return the form to the sender. .

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