Fast Track Home Health and Hospice Referral

Face to Face Encounter
Face-to-Face Visit Date*

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Date
Face-to-Face Reason*
Please be as descriptive as possible.
Physician’s clinical findings to Support homebound status*
Please provide any supporting documentation such as hospital discharge summary, labs, last office visit notes and medication profile. This may alleviate us having to contact you for additional information:
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Physician Signature*

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Physician Phone Number

Area CodePhone Number
Physician Fax Number

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Evaluate & Treat as Indicated