(TER to KP Direct Referrals) - The CHP Group 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Referring Kaiser Clinician' and 'Treating CHP Provider' fields, along with their respective phone numbers. This information is crucial for communication regarding the referral.
3. Indicate the type of initial KP referral by checking the appropriate box and entering the Initial KP Auth # if available.
4. Complete patient details including 'Patient Name', 'Kaiser I.D. #', and 'Fax'. Ensure accuracy as this information is vital for processing.
5. In the treatment section, specify the number of authorized treatments used and how many treatments have been utilized this calendar year.
6. Request additional treatments by checking the relevant option (Chiropractic, Acupuncture, Naturopathic) and indicate how many additional treatments are requested along with the dates.
7. Provide detailed information on initial complaints, pain scores, objective findings, diagnosis, treatment provided, response to treatment, current complaints, objective findings, and expected outcomes.
8. Finally, sign and date the form before forwarding it via fax to Kaiser Permanente Community Medicine Integration Center at 877-800-5456.

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