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