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Referral Form

    ADDENDUM TO PLAN OF CARE


    Responsible Relative/Friend/Caregiver:


    Physician Details:

    Sender Details:


    *** This document serves both as the certifying physician’s order for home health care services for the identified patient as well as the physician’s certification of the Face-to-Face Encounter documentation under Clinical Findings, in support of the Medical Condition and the patient’s Homebound Status.




    Please complete and sign. ALL FIELDS ARE REQUIRED in compliance with Medicare requirements.



    Face-to-Face Visit Attestation:

    I certify that this patient is under my care and that I, or a nurse practitioner/clinical nurse specialist/certified nurse midwife or physician assistant working in collaboration with me or under my supervision, had a faced-to-face visit encounter that meets the physician Face-to-Face encounter requirements with this patient on:

    Medical Condition:

    The encounter with the patient was directly related to the following medical condition(s), which is/are the primary reason for home health care:

    Clinical Findings in Support of Patient’s Eligibility:

    Provide a summary of clinical findings that support the patient’s eligibility for home health services, including specific need for intermittent skilled nursing and/or therapy services. The face-to-face visit finding must be related to the primary reason for home health admission.

    Statement of Homebound Status:

    I certify that the patient’s clinical condition, as evidenced in the face-to-face encounter, supports that this patient is homebound per CMS guidelines (i.e., absences from home require considerable and taxing effort and are for medical reasons or religious services OR are infrequent or of short duration when for other reasons include: physical conditions, mental impairments, physician-ordered restriction(s) due to:




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