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FLORIDA HEALTH CARE PLANS REFERRAL FORM - FHCP - medicare dme providers near me

FLORIDA HEALTH CARE PLANS REFERRAL FORMPhone: 386-238-3230 Fax: 386-238-3253 800-352-9824 855-442-8398Date: FORMTEXT ?????Auth #: FORMTEXT ?????A. Member Name: FORMTEXT ?????Referring Provider Name: FORMTEXT ?????MRN: FORMTEXT ?????Date of Birth: FORMTEXT ?????Contact/Caller Name: FORMTEXT ?????Home Tel: FORMTEXT ?????Work Tel: FORMTEXT ?????Referring Provider Phone #: FORMTEXT ?????Cell #: FORMTEXT ?????Referring Provider FHCP #: FORMTEXT ?????Subscriber #: FORMTEXT ?????Provider Signature:Parent / Guardian Name: FORMTEXT ????? FORMCHECKBOX Referral at Patient Request OnlyB. REFERRAL STATUS: FORMCHECKBOX Routine FORMCHECKBOX Urgent Is this the result of an auto or work accident? FORMCHECKBOX Yes FORMCHECKBOX No *** For urgent cases requiring prior authorization, the provider office must call Central Referrals Department at the number listed above. ***Please refer to your Provider Referral Guide for assistance in completing all referrals.C. REFERRAL IS FOR: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????D. DIAGNOSIS CODE FORMTEXT ? ???? FORMCHECKBOX Eval FORMCHECKBOX Follow Up FORMCHECKBOX 2nd Opinion E. REASON FOR REFERRAL – TO BE COMPLETED BY CLINICIAN (Attach all Supporting Documentation) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????F. THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider. FORMCHECKBOX APPROVED BY FLORIDA HEALTH CARE PLANS FOR: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature: FORMTEXT ?????Date: FORMTEXT ?????G. Appointment with: FORMTEXT ?????Date: FORMTEXT ?????Time: FORMTEXT ????? Notes: FORMTEXT ????? FORMTEXT ????? Confirmed with: FORMTEXT ?????By: FORMTEXT ?????On: FORMTEXT ?????10762_ALL 0520

Does Medicare cover DME? Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims they submit.