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Home Health Face-To-Face Encounter Certification

 I, a Medicare-enrolled physician, or  non-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 homebound homebound 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):
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.

Patient Information

 Male Female
Languages Spoken
 English Spanish Hungarian Russian Chinese Other
(Select all that applies)
Please Specify other Languages:
Emergency Contact/Relationship:
 Alone Family Caregiver
Mental Status: Oriented Confused Forgetful

Insurance Information

Services Requesting

 Nursing Physical Therapy Speech Therapy Aide: HHA Occupational Therapy Social Work



Physician Information

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