Home Health Referral | Physician Face to Face Encounter
Date of Birth
Social Security Number
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
Skilled Nusing Physical Therapy Occupational Therapy Speech Therapy Home Health Aide
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)
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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Document Name: Home Health Referral | Physician Face to Face Encounter
Agree & Sign