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DIAGONISIS / MEDICAL CONDITION:
SKILLED SERVICES / INTERVENTIONS: (Describe services the nurse or therapist will perform in the home, e.g. assess, teach, wound care, gait training.)
CERTIFICATION FOR FACE-TO-FACE ENCOUNTER
I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me or aphysician who cared for the patient in an acute or post-acute facility had a face-to-face encounter related to the primary reasonthe patient requires home health that meets CMS or insurer requirements with this patient on:
Based on the above findings, I certify that this patient is confined to the home and needs intermittent skilled nursing, physicaltherapy, and/or speech therapy. The patient is under my care and I have initiated the establishment of the plan of care for homehealth.
OPTIONAL PHYSICIAN DOCUMENTATION
This section is provided for the physician’s convenience and record keeping in the event of a Medicare audit.
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This form is HIPPA compliant and encrypted for the patients privacy.