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Patient Information

Sex*

Male
Female

Name*

Address*

Date of Birth

Social Security

Phone*

Cell Number

Primary Language*

Insurance Information

Medicare #

Medicaid #

Commercial Insurance

Policy #

Group #

Referral Source Contact

Name*

Organization

Phone*

Email*

Emergency Contact 1

Name

Relationship

Phone

Email

Emergency Contact 2

Name

Relationship

Phone

Email

Home Care Orders

Requested Services

Home Care Diagnosis

Gait Ambulatory Status

Bedbound
Assistive Device
Unassisted

Wound Care Orders

Orders Attached

Orders Attached

Medications - Dose, frequency and route.

List Attached

List Attached

Physician Signing Home Care

Physician Name

Phone

Fax

Address

NPI #

License

Office Contact

Signature

Date

Face-to-Face Encounter Certification

Patient Name

Certification of face-to-face encounter

I Certify that that a face-to-face encounter was performed on the above named patient.

On

Perfomed by

Who is a

Medicare enrolled physician or
a permissible non-physician practitioner

Clinical reason for encounter

The patient's clinical condition, as observed during the encounter, supports the patients homebound status as follows:

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Patient Information

Insurance Information

Referral Source Contact

Emergency Contact 1

Emergency Contact 2

Home Care Orders

Physician Signing Home Care

Face-to-Face Encounter Certification

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