florida health care plans east volusia area network referral instructions

NEUROLOGY
Preferred Medical Centers – Daytona Beach
Mary J. Derbenwick, M.D. #000693
Patients 12 years and older
350 N. Clyde Morris Blvd., Daytona Beach, FL 32114 386 / 238-3244
Fax: 386 / 238-3269
URGENT REFERRAL INSTRUCTIONS: Complete the FHCP Referral form. Pre-authorization from the FHCP Referral Department is not
needed. Distribute the form as follows: Pink: Attach pertinent dictation and forward to the specialist’s office via fax # 386 / 238-3269. The
specialist’s office will review, schedule and notify the patient of their appointment. Upon completion, the specialist’s office will notify the
requesting provider of the appointment date and time. After notification of the appointment information, the White copy will be completed by the
referring provider and sent to the FHCP Daytona Beach Referral Department. Yellow: To be retained in the requesting provider’s records. Blue:
Give to the member as documentation of the referral request.
REFERRAL INSTRUCTIONS: Complete the FHCP Referral form. The requesting provider should call this specialist 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 and Pink: Attach pertinent documentation and
dictation and forward to the specialist’s office via FHCP courier. Yellow: To be retained in the requesting provider’s records. Blue: Give to the
member as a reminder of their appointment date and time.
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EAST 06/01/08