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Home Health Face-To-Face Encounter Certification

Physician NPI:

Home Care Agency:

I, a Medicare-enrolled physician, ornon-physician preactitioner*(Check One)
had a face-to-face encounter with the above-named patient on
for the following medical condition(s) ,
which is related to the primary reason the patient needs home care.

The following clinical findings support that the patient is homeboundhomebound means that there exists a normal inability to leave home, and consequently, leaving home requires considerable and taxing effort)and that the patient needs intermittent skilled nursing and/or therapy (physical or occupational therapy or speech pathology):

Homebound:

Skilled Need:

* Per CMS's Regulation (42 C.F.R 424.22), "the physician responsible for performing the initial certification must document that the face patient encounter, which is related to the primary reason the patient requires home health services, has occurred." This documentation must include the "date of the encounter, an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing or therapy services as defined in 409.42 (a) and (c)."

** A non-physician practitioner includes a nurse practitioner, clinical nurse specialist working in collaboration with the physician, a certified nurse midwife or a physician assistant under the supervision of the physician.

Referrals

Download PDF Referrals Form:

Home Health Face-To-Face Encounter Certification

Patient Information

Insurance Information

Services Requesting

Diagnosis

Medications/Dose/Frequency

Physician Information

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Patient Name:
Admission ID:
Physician Signing Certification:

Last Name:
First Name:

Medicare #:
Mediciad #:

Last Name:
First Name: