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Physician Certification of Need and Orders for Home Health Services
Date of Birth:
Physician Ordering Home Health Services:
Address for Care:
Primary Problem for Home Health Care:
Event Prompting Referral
Hospital/Facility stay from
for primary problem noted above. Hospital/SNF Physician or NPP* may complete the attestation of face to face encounter within 90 days prior to Start of Care date for Home Health Services.
Face to Face encounter on
primary problem for Home Health. Encounter must be within 90 days prior to Start of Care date for Home Health Services.
No Face to Face encounter for the primary problem note above has occurred within the past 90 days.
CMS Requirements If No Face To Face
Encounter Due Date:
Must be within 30 days after SOC – see order date in “services ordered” area
Physician who will perform (or have NPP* perform) the Face to Face encounter and oversee the Plan of Care:
Care Plan Oversight
Will the ordering physician sign and oversee the plan of care:
If No, which Physician is to sign and oversee the Plan of Care?
Choose one box with your order for SOC date:
SOC on a specific date
Within 48 hours of SOC referral (standard)
The following services are medically necessary:
Home Health Aide
Medical Social Worker
Attestation Of Face To Face Encounter
My clinical findings support the need for home health services as follows:
I certify my clinical findings support that this patient is homebound per cms guidelines due to:
(Include physical conditions, mental impairments, physician-ordered restrictions)
I CERTIFY that this patient is under my care and that I had a face to face encounter that meets the Physician Face to Face requirements with this patient as noted above.