Home Health Face-to-Face Encounter Certification


Patient Name

Date of Birth

Date of Physician Encounter

Name of Physician or NPP who Performed the Encounter

Name of Certifying Physician (if visit was performed by NPP)

Patient Chief Complaint/Reason for Visit

Medical Condition and Home Health Services Needed (Reason for visit must be directly related to the home health services being provided)

Patient is Homebound Due To 

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HIPPA Compliant and Secure

I certify the face to face encounter occurred as noted above and clinical conditions exhibited during the encounter are related to the primary reason for home care unless indicated otherwise. I certify that this patient is confined to his/her home and needs intermittent skilled care. The patient is under my care, and I have authorized the services on this initial order and will periodically review the plan of care.

 

**If you do not have an email address, please use info@nationalhhc.com in the field below**

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Signature Certificate
Document name: Home Health Face-to-Face Encounter Certification
Unique Document ID: 8307df07678ca548d6402de1b5ed334b3791dfa8
Timestamp Audit
2016-11-08 08:59:04 EDTHome Health Face-to-Face Encounter Certification Uploaded by National Home Healthcare - forms@nationalhhc.info IP 69.243.214.34