florida health care plans east volusia area network referral instructions

LYMPHEDEMA CLINIC
Halifax Health #00Y007 201 N. Clyde Morris Blvd., 3 rd. Floor, Daytona Beach, FL 32114 386 / 258-4969
Fax: 386 / 947-4645
Ability Health Services #010415 401 Venture Blvd., Suite C, South Daytona, FL 32119 386 / 763-0084
Fax: 386 / 763-0085
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.
MAMMOGRAMS
Twin Lakes Imaging Center #F00001 1890 LPGA Blvd., Suite 110, Daytona Beach, FL 32124 386 / 274-5454
Fax: 386 / 274-5440
Port Orange Imaging Center #F00002 1195 Dunlawton Avenue, Port Orange, FL 32127 386 / 322-1616
Fax: 386 / 322-5330
Florida Hospital Imaging 335 Clyde Morris Blvd., Ormond Beach, FL 32174 386 / 671-9090
Fax: 386 / 671-9494
REFERRAL INSTRUCTIONS: Diagnostic Mammograms: Complete the FHCP Referral form. The requesting provider should call this facility
directly, while the member is present 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 the Referral Department at the Daytona Beach facility. Pink: Send, via FHCP courier, with attached dictation,
documentation, and previous Mammogram films to the appropriate facility. Yellow: To be retained in the requesting provider’s records. Blue: Give
to the member as a reminder of their appointment date and time.
Screening Mammogram: A Screening Mammogram order can be placed on a prescription pad. Please include patient name, date, specify
screening mammogram, physician name, physician address, physician phone number, and physician signature. The order and the list of FHCP
Screening Mammography locations (02-662/10-04RP) should be given to the member for her to schedule her appointment.
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EAST 06/01/08