Referral Form

Your Name (required)

Date

Address (required)

SSN

DOB

Phone (required)

Emergency Contact Person

Phone (required)

PCP(required)

Phone (required)

Insurance

Medicare(required)

Medicaid (required)

Other Insurance

Policy

FLU Vaccine (required)

YesNoIf yes , Date

Pneumonia Vaccine (required)

YesNoIf yes , Date

Wound Care (required)

YesNoIf yes , Date

Services Requested by Physician

Skilled nursing (required)

Evaluation & TreatWound CareDiabetes TeachingLabsHome Health AideOther

Therapy (required)

Physical TherapyMedical Social ServicesOccupational TherapyEvaluation & TreatSpeech Therapy

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

P.T/O.T

S.T

MSW

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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Doctor's signature (required)

Doctor's Name

Date:

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