florida health care plans east volusia area network referral instructions

PULMONARY FUNCTION TESTS (PFTs)
Florida Hospital – Flagler #00Y015
Respiratory Dept.
60 Memorial Medical Parkway, Palm Coast, FL 32168 386 / 437-2211
Fax: 386 / 586-4618
REFERRAL INSTRUCTIONS: Complete the FHCP Referral form. The requesting provider should call this department directly to schedule an
appointment. Pre-authorization from the FHCP Referral Department is not needed. Confirm the appointment with the member and record the
appointment date and time at the bottom of the request form. Distribute the form as follows: White: Send, via FHCP courier, to attention of Referral
Advisor in FHCP’s Palm Coast Facility. Pink: Have the patient hand carry to the hospital to verify coverage of this schedule test. Yellow: To be
retained in requesting provider’s records. Blue: Give to the member as a reminder of their appointment date and time.
PULMONARY REHABILITATION
Halifax Health #00Y007 201 N. Clyde Morris Blvd., 3 rd. Floor, Daytona Beach, FL 32114 386 / 947-4644
Fax: 386 / 258-4804
REFERRAL INSTRUCTIONS: Complete the FHCP Referral form. Attach pertinent documentation and dictation needed to substantiate this
request. Distribute the form as follows: White, Pink, & Yellow: Send to the Referral Department at FHCP’s Daytona Beach facility, via FHCP
courier. Blue: Give to the member.
The Referral Department will review the request and if approved, will schedule the member’s appointment with this specialist, record the
appointment date and time on the request form and return the completed Yellow copy to your office for your records.
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FLAGLER 06/01/08