Referrals Jun 12, 2013 Download PDF Referrals Form: Click Here to download PDF Referrals Form. Home Health Face-To-Face Encounter Certification Patient Name: Admission ID: Physician Signing 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: Physician Signature: * 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. Patient Information Last Name: First Name: Gender: MaleFemale D.O.B. Address: City: State: Zip: Tel#: S.S.#: Languages Spoken EnglishSpanishHungarianRussianChineseOther (Select all that applies) Please Specify other Languages: Emergency Contact/Relationship: Lives with: AloneFamilyCaregiver Mental Status: OrientedConfusedForgetful Insurance Information Medicare #: Mediciad #: Services Requesting NursingPhysical TherapySpeech TherapyAide: HHAOccupational TherapySocial Work Hours: Days: Diagnosis Medications/Dose/Frequency Physician Information Last Name: First Name: M.I. Address: City: State: Zip: Tel. #: License #: UPIN #: NPI #: Doctors Orders: Would Care Orders: MD Only BG Parameters: PT only WB Status: MD Signature: Enter the code below: To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.