Home Health Agency Face to Face Form

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Home Health Agency Face to Face Form Powered By Docstoc
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                              Face-to-Face Encounter for
                             Medicare Home Health Patient
Patient Name: __________________________                 DOB: ____________                   MR: ___________

I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant
working with me, had a face-to-face encounter that meets the physician face-to-face encounter
requirements with this patient on: (Insert date that visit occurred): _____/______/_____
                                                                          Month Day Year
Medical Condition:

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):
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Medical Necessity:

I certify that, based on my findings, the following intermittent skilled services are medically necessary
home health services (check all that apply):

___ Skilled Nursing                   ___ Occupational Therapy               ___MSW
___ Cardiac/CHF Care                  ___ Diabetic Care                      ___Neurological Care
___ Ostomy Care                       ___ Stroke Care                        ___Home Health Aide
___ Physical Therapy                  ___ Speech Therapy                     ___Orthopedic Care
___ COPD Care                         ___ Medication Management              ___Other: ____________________
___ Strengthening/Balance             ___Wound Care

Clinical Findings
My clinical findings support the need for the above services because:
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Homebound Status

Further, I certify that my 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 and of short duration when for other reasons) because:
_____________________________________________________________________________________
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Physician Signature(Attending) _______________________ Date of Signature: _____/______/_____

Physician Name: _______________________
                                                            Fax completed form to: ________________

				
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posted:3/30/2011
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Description: On April 1, 2011, all patients needing Medicare reimbursed for home health care services will be required to have a documented face to face encounter with an eligible health care provider within the 90 day period before or 30 days after the initiation of needed home health care services. This an EASY to SAVE and complete form.
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PARTNER Alexis Oriol Rodriguez Caceres
Doctor en Medicina, Especialista en Medicina Familiar, Diplomado en Educacion Medica Superior y Cuidados Criticos. Especialista en Sistemas Informaticos. GNU LINUX DEBIAN Linux Registered User 282077