Referral Form
  1. Patient Name :(*)
    This field is required
  2. Patient Address : (*)
    This field is required
  3. Phone Number :(*)
    This field is required
  4. Medicare Number :(*)
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  5. Other Insurance :
    This field is required
  6. Date of Birth :(*)
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  7. Gender :(*)
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  8. Caregiver Name :(*)
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  9. Caregiver Phone :
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  10. Orders :
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  11. Referral Date :(*)
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  12. Attestation of Face-to-Face Encounter
    A face-to-face encounter that meets the CMS requirements for this patient occurred on:
  13. Date of Face-to-Face Encounter :
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  14. The encounter/assessment with the patient was in whole, or in part, for the following medical conditions(s), which is the primary reason for home health care.
  15. List medical conditions :
    This field is required
  16. I certify that based on my findings, the following services medically necessary home health services.
  17. Check all that Apply :(*)
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  18. Clinical findings that support he need for home health service\'s:
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  19. Further, I certify that the clinical findings support that this patient is home bound (i.e. absences from the home require considerable and taxing effort and are for medical reasons, or religious services, or infrequently or of short duration for other reason) because :
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  20. I certify that this patient has had a face-to-face encounter by myself or Nurse Practitioner or Physician's Assistant working collaboratively with me :
  21. Date :(*)
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  22. Physician Name :(*)
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  23. Physician Signature : (*)
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  24. Time :(*)
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  25. Submit