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Patient Information:
     
Patient's Name :



Date Of Birth :    

Phone :



SSN :



Patient's Street Address :



City :



Texas :



Zip
:



Emergency Contact Name
:



Phone
:



Email
:
Patients Mailing Address:



Same as above? :  

Address :



City :



State :  



Zip :  
Financial Information :



Medicare  



Medicare ID :



Medicaid  



Medicare ID :



Private Insurance  



Insurance Company :



Member ID Number :



Group Number :



Customer Service Phone Number :



Private / Self Pay  



Medicare No. / Other Info :
Diagnosis:


I Certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient on:

   
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care:
Condition :



Orders:


I Certify that, based on my finding the following services are medically necessary for home health services (check all that apply):


Skilled Nurse




Physical Therapy


Occupational Therapy


Speech Therapy


Home Health Aide


Medical Social Worker


Other   





My clinical findings support the need for the above services because:

 :





Further, I certify that my clinical findings support that this patient is homebound (i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because:

:



Physician Information:



Referring Physician :  

Telephone :



date :



Referral Entered By (Name) :
Referral Entered By (Source):

Physician's Office :



Patient (Self) :



Patient Family Member :



Relationship :



Other :