Refer a Patient for Home Health Care

Patient Information:

Date of Referral:

Insurance and ID#:

MedicarePrivate

Diagnosis:

I certify that based on my clinical findings the following services are medically necessary home health services (check all that apply):

Skilled NursingOccupational TherapistSocial WorkerPhysical TherapistSpeech TherapistHome Health Aide

I certify that this patient is under my care and that I, or a nurse practitioner, clinical nurse specialist or physician's assistant working with me, had a face-to-face encounter with this patient on:

Date of Encounter:

My clinical findings from this encounter support the patient is homebound due to:
Leaving home requires a considerable and taxing effort and requires the assistance of another
Pain with movement
Open draining wound
Medically restricted due to immunosuppression, infectious illness, risk of infection, injury, or other

Assess and call pertinent findings to MD for further follow up

Doctor Information:

Date Signed: