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      Patient Intake and Consent Form

      Responsible Relative/Friend/Caregiver:

      Physician Details:

      Sender Details:

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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:

      Medical Condition:

      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:

      Patient Intake and Consent Form

      Please complete our online Patient Demographic Form to register yourself or your loved one for service with HomeMD Housecall Services. Once we receive your intake information along with the signed consent form, a referral specialist will contact you shortly thereafter (usually the same day) to coordinate for the first appointment with our provider staff.

      Patients Address

      Billing Address (if different than patients primary address)

      Primary Insurance Information :

      Secondary Insurance Information :

      Submit Image of Insurance Card ( front )

      Maximum 3MB file size ( jpg, jpeg, png, pdf )
      Click or drag a file to this area to upload.

      Submit Image of Insurance Card ( back )

      Maximum 3MB file size ( jpg, jpeg, png, pdf )
      Click or drag a file to this area to upload.

      Emergency / Health Care Advocate

      Primary Care Information

      ( So that we can coordinate care and/or retrieve records, if we are assuming primary care )
      Please have HomeMD Housecall Services assume housecall based primary care for myself or my loved one


      Please have HomeMD Housecall Services provide me with information about in-home primary care


      Please set me up with a remote monitoring service so that my vital sign readings can be reviewed in real-time by my provider


      Patient History

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      Requested Services

      Primary Care Services Description

      Primary Care Services

      Primary care in the home carried out by experienced nurse practitioners who have beenworking with homebound clients including geriatrics and their families for many years. Our providers are very much tuned in to the frustrations that geriatric clients and their families run into when trying to navigate a very complicated and fragmented medical care system. Diagnostics including labwork and imaging services are provided in the comfort of your livingroom, reducing the need for back and forth >trips to the PCP, which often require family members to take days off work. Our primary care program was designed to empower patients and their families with access to a level of comprehensive care that can’t be found anywhere else while accomplishing it all in one place, your living room.

      Palliative Care Services Description

      Palliative Care Services

      Palliative Care ‐ Runs as a supplement to outside primary care for individuals who require frequent symptom management and/or for patients who need frequent, oftentimes unpredictable “check‐in’s” to put out fires secondary to chronic conditions; clients may keep their current primary care provider whom our clinical team will then coordinate care with.

      Wound Care Services Description

      Wound Care Services

      Receive specialty wound care services in the comfort of your own home.

      Podiatry Care Services Description

      Podiatry Care Services

      Podiatry Care – ankle, foot, and nail care in the home

      Behavioral Heath Psych Care Services Description

      Behavioral Heath / Psych Care Services

      Nurse practitioners/medical providers who are able to make medication adjustments and order treatments centered around behavioral care services. Suitable for depression, isolation, anxiety, dementia, behaviors secondary to dementia, and abnormal psychology. Oftentimes complemented by our counseling services.

      Counseling Services licensed medical social worker Description

      Counseling Services (licensed medical social worker)

      Services provided by licensed medical social workers in the home. Can also be provided telephonically through our tablet program.

      Remote Monitoring Services Description

      Remote Monitoring Services

      Cloud connected blood pressure cuffs, weight scales, and diabetic glucometers that report readings to our office. These devices monitor and report to our provider staff when vital sign readings indicate that there may be a problem. Oftentimes when our providers are alerted to vital signs that may be of concern, this may indicate a need for intervention, which our providers can take either onsite or telephonically.


      *Patients or Advocates Signature of Consent
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