HOME HEALTH CERTIFICATION AND PLAN OF CARE

Department of Health and Human Services Centers for Medicare & Medicaid Services

Form Approved OMB No. 0938-0357
HOME HEALTH CERTIFICATION AND PLAN OF CARE
1. Patient's HI Claim No.
2. Start Of Care Date

MonthDayYear
Date
3. Certification: From

MonthDayYear
Date
To

MonthDayYear
Date
4. Medical Record No.
5. Provider No.
6. Patient's Name and Address
7. Provider's Name, Address and Telephone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
8. Date of Birth

MonthDayYear
Date
9. Sex

MF
10. Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD-9-CM
Principal Diagnosis
Date

MonthDayYear
Date
12. ICD-9-CM
Surgical Procedure
Date

MonthDayYear
Date
13. ICD-9-CM
Other Pertinent Procedure
Date

MonthDayYear
Date
14. DME and Supplies
15. Safety Measures
16. Nutritional Req.
17. Allergies
18-A. Functional Limitations

AmbulationBowel/Bladder (Incontinence)ContractureHearingParalysisEnduranceEnduranceAmbulationSpeechLegally BlindDyspnea with minimal exertionOther
18-B. Activities Permitted

Complete BedrestBedrest BRPUp As ToleratedTransfer Bed/ChairExercises PrescribedPartial Weight BearingIndependent At HomeCrutchesCaneWheelchairWalkerNo RestrictionsOther
Mental Status

OrientatedComatoseForgetfulDepressedDisorientedLethargicAgitatedOther
Prognosis

PoorGuardedFairGoodExcellent
Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
Goals/Rehabilitation Potential/Discharge Plans
Nurse's Signature

Clear
Date of Verbal SOC Where Applicable:

MonthDayYear
Date
Date HHA Received Signed POT

MonthDayYear
Date
Physician Name

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
26. I certify/recertify that this patient is confined to his/her home and needsintermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized the services on this plan of care and will periodically review the plan.

Clear
27. Attending Physician's Signature and Date Signed

Clear
28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Clear
Form CMS-485 (C-3) (02-94) (Formerly HCFA-485) (Print Aligned)
Privacy Act Statement
Sections 1812, 1814, 1815, 1816, 1861, and 1862 of the Social Security Act authorize collection of this information. The primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals. Disclosure of this information may be made to : Peer Review Organizations and Quality Review Organizations in connection with their review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Social Security Act; State Licensing Boards for review of unethical practices or nonprofessional conduct; A congressional office from the record of an individual in response to an inquiry from the congressional office at the request of that individual.

Where the individual's identification number is his/her Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.
Paper Work Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this informa tion collection is 0938-0357. The time required to complete this information collection is estimated to aver- age 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
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HOME HEALTH CERTIFICATION AND PLAN OF CARE

Privacy Act Statement

Paper Work Burden Statement