Home Health Referral | Physician Face to Face Encounter

Patient Name

Date of Birth

Social Security Number


Phone Number

Alternate Contact

Primary Insurance


Date of Patient Visit (Face to Face Encounter)




Patient’s condition during encounter relating to need for home care


Services needed and clinical findings to support services based on encounter


Clinical findings that support this patient is homebound (i.e.: needs assistance for all activities, residual weakness, require max assistance/taxing effort to leave home, confusion/unsafe to go out of home along, severe SOB/SOB upon exertion, unable to safely leave home unassisted and/or any other clinical factors that affect homebound status)

Physician Name 



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 authorize the services on this initial order and will periodically review the plan of care. 

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Signature Certificate
Document name: Home Health Referral | Physician Face to Face Encounter
Unique Document ID: fd7348fcd75f2f4f5d233b550ae123e9681c6a56
Timestamp Audit
2016-11-21 14:12:00 EDTHome Health Referral | Physician Face to Face Encounter Uploaded by National Home Healthcare - forms@nationalhhc.info IP