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List Attached
List Attached
Physician Signing Home Care
Physician Name
Phone
Fax
Address
Street Address
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State
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Signature
Date
Month
Day
Year
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
Month
Day
Year
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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