FHCP PRECERTIFICATION FORM
8255-41719500FLORIDA HEALTH CARE PLANSP.O. BOX 10348DAYTONA BEACH, FL 32120-0348CENTRALS REFERRALS DEPARTMENTAUTH #: FORMTEXT ? ????FAX – 386-238-3253 / 855-442-8398 PHONE – 386-238-3215 / 800-729-8349 PRIOR AUTHORIZATION FORMTHIS FORM IS INTENDED TO REPRESENT THE PROVIDER’S ORDER FOR SERVICES OR SUPPLIESPLEASE FAX ALL PERTINENT CLINICAL INFORMATION TO FHCP AT THE NUMBER LISTED ABOVE. THIS MAY INCLUDE LABS, RADIOLOGY, PATHOLOGY REPORTS & OTHER DIAGNOSTIC STUDIES INCLUDING H&P AND/OR PROVIDER NOTES. TAX ID #: FORMTEXT ?????DATE: FORMTEXT ?????Is this the result of an auto or work related accident? FORMCHECKBOX Yes FORMCHECKBOX NoREQUESTING PROVIDER NAME: FORMTEXT ?????TYPE OF REFERRAL: FORMCHECKBOX ROUTINE FORMCHECKBOX URGENT (call if urgent)CONTACT NAME: FORMTEXT ?????PHONE NUMBER: FORMTEXT ?????EXT: FORMTEXT ?????FAX: FORMTEXT ?????Patient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????FHCP Medical Record #: FORMTEXT ?????Patient Phone #(s): FORMTEXT ?????A. Surgical Procedure: FORMTEXT ?????CPT Code: FORMTEXT ?????Diagnosis: FORMTEXT ?????ICD-10 Code: FORMTEXT ?????Surgical Procedure Date: FORMTEXT ?????Surgeon: FORMTEXT ????? Facility Name: FORMTEXT ????? Address: FORMTEXT ????? FORMCHECKBOX Inpatient FORMCHECKBOX Outpatient FORMCHECKBOX 23 Hour OBS * Admit Date FORMTEXT ?????Expected Length of Stay FORMTEXT ????? *Documentation is required to support 23 Hour OBS statusPre-Op Testing Date: FORMTEXT ?????Physicians Pre-op Visit Date: FORMTEXT ????? B. OFFICE VISIT / TEST REQUESTED: (Name Provider or Test) FORMTEXT ????? Test Test Test With & FORMCHECKBOX Initial evaluation FORMCHECKBOX Follow up FORMCHECKBOX With Contrast FORMCHECKBOX Without Contrast FORMCHECKBOX Without ContrastAppt Date: FORMTEXT ?????Testing Facility Name: FORMTEXT ?????DX: FORMTEXT ?????ICD-10 Code: FORMTEXT ????? **** THIS SECTION FOR INTERNAL USE ONLY**** Payment will not be authorized for services beyond those indicated below. **** FORMCHECKBOX Approved by Florida Health Care Plans for: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Signature: ______________________________________________________________________Date:__________________________ ................
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