Home Health Face-to-Face Encounter Certification
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
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 firstname.lastname@example.org in the field below**
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Home Health Face-to-Face Encounter Certification
Agree & Sign