Inpatient Admission Notification

Use this form to notify our Care Management department when a Kaiser Permanente member is admitted to a hospital or other inpatient or observatory facility. The admission will be reviewed within 3 business days. After that time, you can check its authorization status on our online Referral Status Inquiry tool.

Patient Information

*Indicates a required field

*First name:

MI:

*Last name:

*Member ID #:

*Date of birth: MM/DD/YYYY

*Patient-reported insurance coverage: (Report all that apply - maximum 1,200 characters) characters remaining

*Primary care physician:

Facility and Diagnosis Information

*Facility name:

*Facility Tax ID #:

*Admit date: MM/DD/YYYY

*Admit time: Use 24-hour format without a colon (for example, 0700 or 1830)

*Admitting physician:

*Attending physician:

*Room and bed #:

*Admit status:

*Admit source:

*Other admit source:

*Diagnosis code:

*Diagnosis description: (maximum 1,200 characters) characters remaining

Procedure code:

Procedure description: (maximum 1,200 characters) characters remaining

Your Contact Information

*Name:

*Phone #:

Ext:

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