American College of Physicians
Documentation of Face-to-Face EncounterPatient Name: _________________________________ Date of Birth: _____/____/_____Face to Face Encounter (Date of last MD appointment)” _______/_______/______ Month Day YearPrimary diagnosis and reason for home health care services:Clinical findings to support the need for services:The following services are medically necessary home health care services:_____Skilled Nursing_____Physical Therapy_____Speech Therapy_____Occupational Therapy The clinical findings support that this patient is homebound (i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because:Physician Signature: _____________________________________________________________Date of Signature: _____/_____/_____Physician Printed Name: _________________________________________________________ ................
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