Physician Home Health Certification Statement

Attestation of Home Health Certification / Face to Face Encounter Documentation

1 TO BE COMPLETED BY THE FACILITY (required for Medicare patients at SOC only – do not use for Resumption)

Patient Name: (Last, First)______

DOB: ______

2 TO BE COMPLETED BY THE PHYSICIAN (or designee on their behalf) THAT HAD THE FACE TO FACE ENCOUNTER

Face to Face encounter date: ______Month Day Year I certify that the following services are medically necessary for this patient, based on my clinical findings below:

 Skilled Nurse  Physical Therapy  Speech Therapy

To provide the following care/treatments:

The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care (List medical condition, reason for face to face encounter):

My clinical findings support the need for the above services because:

I certify my clinical findings support that this patient is homebound per CMS guidelines due to:

(May include physical conditions, mental impairments, physician-ordered restrictions, weakness, SOB, infection risk, absences from home which require considerable and taxing effort and are for medical or religious reasons or infrequently for short durations)

I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. This patient is or has been under my care, and I have authorized the services on this certification. 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.

______Physician Signature Signature Date

Content of form based on CMS Calendar Year 2011 Final Rule Face to Face Encounter requirements. Home Health Addendum / Face to Face Encounter Documentation