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About Us
Home Care Privacy Practices
Home Health Services
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Consumer Directed Services
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Private Duty Services for Veterans
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Physician Face-to-Face Reference
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Physician Face-to-Face Reference
CMS Home Health Physician Face-to-Face Encounter - Physician Face-to-Face Reference
Patient Name
Home health start date
MM slash DD slash YYYY
Patient DOB
MM slash DD slash YYYY
1) I certify that I, or a nurse practitioner or physician's assistant working with me, had a Face to Face encounter with this patient on the date indicated below. This date needs to have occurred
within 90 days prior
OR
within the 30 days after
the Home Health episode start of care date.
Encounter date
MM slash DD slash YYYY
2) The encounter with the patient was in whole, or in part, for the following medical condition(s), which is the primary reason for home health care.
Please list patient active diagnosis for home care:
3) I certify that, based on my findings, the following services are medically necessary home health services and
my clinical findings support the need for these services because:
4) I certify that my clinical findings support that
the patient is HOMEBOUND requiring a taxing effort to leave home because:
Date
*
MM slash DD slash YYYY
Physician printed name
*
Signature
*
Use your curser (or finger on a tablet or mobile device) to write your signature above.
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