Request for Service Form

Please take a moment to fill out the form.

Date

Organization/Office

Patient's Social Security Number

City

Medicare #

Requester's Name

Patient's Name

Patient's Phone #

Zip

Medicaid #

Phone Number

Date Of Birth

Patient's Address

Patients Insurence Information

Private

Primary Physician

Special Instructions

CERTIFICATION FOR FACE-TO-FACE ENCOUNTER

I certify that this patient is under my care and that I, or a nurse practitioner or physician's assistant working with me or a physician who cared for the patient in an acute or post-acute facility had a face-to-face encounter related to the primary reason the patient requires home health that meets CMS requirements with this patient on:

REQUIRED: face-to-face Encounter

Based on the above findings, I certify that this patient is confined to the home and needs intermittent skilled nursing, physical therapy, and/or speech therapy. The patient is under my care and I have initiated the establishment of the plan of care for home health.

Signature Date

Physician's Printed name

Physician Signature

Optional Physician Documentation

This section is provided for the physician's convenience and record keeping in the event of Medicare audit

CLINICAL FINDINGS:(signs and symptoms of medical condition exhibited by the patient during the encounter that support the need for all services listed above.)

Homebound Status: (Describe the clinical and / or physical findings and the functional limitations that result in the patient's normal inability to leave home.)

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