CMS Home Health Physician Face-to-Face Encounter - Physician Face-to-Face Reference

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 1) I certify that I, or a nurse practitioner or physician's assistant working with me, had a Face to Face encounter with this patient on the date indicated below. This date needs to have occurred within 90 days prior OR within the 30 days after the Home Health episode start of care date.
  • Date Format: MM slash DD slash YYYY
  • 2) The encounter with the patient was in whole, or in part, for the following medical condition(s), which is the primary reason for home health care. Please list patient active diagnosis for home care:
  • 3) I certify that, based on my findings, the following services are medically necessary home health services and my clinical findings support the need for these services because:
  • 4) I certify that my clinical findings support that the patient is HOMEBOUND requiring a taxing effort to leave home because:
  • Date Format: MM slash DD slash YYYY
  • Use your curser (or finger on a tablet or mobile device) to write your signature above.