Responsible Relative/Friend/Caregiver:
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*** This document serves both as the certifying physician’s order for home health care
services for the identified patient
as well as the physician’s certification of the Face-to-Face Encounter documentation under
Clinical Findings,
in support of the Medical Condition and the patient’s Homebound Status.
Please complete and sign. ALL FIELDS ARE REQUIRED in compliance with Medicare requirements.
Face-to-Face Visit Attestation:
I certify that this patient is under my care and that I, or a nurse practitioner/clinical
nurse specialist/certified nurse midwife or physician assistant working in collaboration with me
or under my supervision, had a faced-to-face visit encounter
that meets the physician Face-to-Face encounter requirements with this patient on:
The encounter with the patient was directly related to the following medical condition(s), which
is/are the primary reason
for home health care:
Clinical Findings in Support of Patient’s Eligibility:
Provide a summary of clinical findings that support the patient’s eligibility for home health
services, including specific
need for intermittent skilled nursing and/or therapy services. The face-to-face visit finding must
be related to the primary
reason for home health admission.
Statement of Homebound Status:
I certify that the patient’s clinical condition, as evidenced in the face-to-face encounter, supports
that this patient is
homebound per CMS guidelines (i.e., absences from home require considerable and taxing effort and
are for medical
reasons or religious services OR are infrequent or of short duration when for other reasons include:
physical conditions,
mental impairments, physician-ordered restriction(s) due to:
