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Physician Certification of Need and Orders for Home Health Services
Patient Name:*
Date of Birth:* SNN #:
Sex:*    Male    Female
Physician Ordering Home Health Services: Dr:
*Phone: Fax:
Telephone: Alternate Phone:
Address for Care:
Primary Problem for Home Health Care:
Additional Diagnoses:
Primary Insurance: Insurance Number:
Secondary Insurance: Insurance Number:
Event Prompting Referral
Hospital/Facility stay from to 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:    YesNo
If No, which Physician is to sign and oversee the Plan of Care?
Services Ordered
Choose one box with your order for SOC date:
SOC on a specific date OR
Within 48 hours of SOC referral (standard)
The following services are medically necessary:
Skilled Nurse Speech Therapy
Physical Therapy Home Health Aide
Occupational Therapy 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.

* Security Code