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    FLU Vaccine (required)

    YesNoIf yes , Date

    Pneumonia Vaccine (required)

    YesNoIf yes , Date

    Wound Care (required)

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    Skilled nursing (required)

    Evaluation & TreatWound CareDiabetes TeachingLabsHome Health AideOther

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    Medicare Face-to-Face Encounter (required)

    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 face-to-face visit encounter that meets the physician encounter requirements with this patient on : Date of in person visit

    Medical Condition : The encounter with this patient was directly related to the following medical condition, which is 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, The face-to-face visit findings must be related to the primary reason for home health admission.

    Skilled Nursing




    Home Health Aide

    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 home bound (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) due to :

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