REFER A PATIENT

Home Health Referral, Physician Order & Face-to-Face Certification

Please complete all applicable sections. All patient information is kept strictly confidential in accordance with HIPAA regulations.

Patient Information

Patient Full Name*

Date of Birth

Phone Number

Address

Insurance Provider

Insurance ID / Member #

Primary Diagnosis

Secondary Diagnoses

Reason for Home Health Services

"I certify that this patient had a face-to-face encounter related to the primary reason for home health services."

Date of Encounter

Encounter Performed By

Clinical Findings Supporting Homebound Status

Patient requires assistance to leave homeLeaving home requires considerable effortPatient has medical restrictions

"I certify that this patient is under my care and requires intermittent skilled services. I approve the plan of care and confirm homebound status."

Physician Name

Practice Name

Phone

Fax

NPI Number

Signature (Draw or Type)

Sign here

Date

Upload supporting documents. Accepted formats: PDF, JPG, PNG, DOC, DOCX.

Face Sheet

Insurance Card

Discharge Summary

Orders

By submitting, you confirm the information above is accurate and complete.