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) |
| |
|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 |
| I certify that the following services are medically necessary for this patient, based on my clinical findings below: |
| |
|θ Skilled Nurse θ Physical Therapy θ Speech Therapy |
| |
|To provide the following care/treatments: |
| |
| |
| |
|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
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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