Physician Home Health Certification Statement



Attestation of Home Health Certification / Face to Face Encounter Documentation

|1 TO BE COMPLETED BY THE FACILITY (required for Medicare patients at SOC only – do not use for Resumption) |

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|Patient Name: (Last, First)______________________________________________________________ |

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|DOB: ______________________________ |

|2 TO BE COMPLETED BY THE PHYSICIAN (or designee on their behalf) THAT HAD THE FACE TO FACE ENCOUNTER |

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|Face to Face encounter date: ______________________________________________________ |

|Month Day Year |

| I certify that the following services are medically necessary for this patient, based on my clinical findings below: |

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|θ Skilled Nurse θ Physical Therapy θ Speech Therapy |

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|To provide the following care/treatments: |

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|The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care (List medical |

|condition, reason for face to face encounter): |

| |

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|My clinical findings support the need for the above services because: |

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|I certify my clinical findings support that this patient is homebound per CMS guidelines due to: |

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|(May include physical conditions, mental impairments, physician-ordered restrictions, weakness, SOB, infection risk, absences from home which require |

|considerable and taxing effort and are for medical or religious reasons or infrequently for short durations) |

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|I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need|

|occupational therapy. This patient is or has been under my care, and I have authorized the services on this certification. Anyone who misrepresents, |

|falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable |

|Federal laws. |

___________________________________________________ ________________________

Physician Signature Signature Date

Home Health Addendum / Face to Face Encounter Documentation

|1 TO BE COMPLETED BY THE FACILITY (required for Medicare patients at SOC only – do not use for Resumption) |

| |

|Patient Name: (Last, First)______________________________________________________________ |

| |

|DOB: ______________________________ |

|2 TO BE COMPLETED BY THE PHYSICIAN (or designee on their behalf) THAT HAD THE FACE TO FACE ENCOUNTER |

| |

| |

|Face to Face encounter date: ______________________________________________________ |

|Month Day Year |

| |

|The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care (List medical |

|condition, reason for face to face encounter): |

| |

| |

|My clinical findings support the need for the above services because: |

| |

| |

|I certify my clinical findings support that this patient is homebound per CMS guidelines due to: |

| |

| |

| |

| |

|(May include physical conditions, mental impairments, physician-ordered restrictions, weakness, SOB, infection risk, absences from home which require |

|considerable and taxing effort and are for medical or religious reasons or infrequently for short durations) |

| |

|I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need|

|occupational therapy. This patient is or has been under my care, and I have authorized the services on this certification. Anyone who misrepresents, |

|falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable |

|Federal laws. |

___________________________________________________ ________________________

Physician Signature Signature Date

___________________________________________________

Physician Printed Name

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