Refer a Patient to Home Health Care

Patient First Name  *Patient Last Name Date of Birth Social Security Number Street Address City State Zip Code Phone Alternate Contact 

Insurance Information

Insurance Provider Member ID# Group # Policy # Primary Policy Holder Relationship to Patient 

Orders

Primary Recommendations 

Additional Recommendations 


Medicare Encounter Documentation

Diagnosis related to primary need for home care Clinical findings that support the need for home health (specific need for nursing and/or therapy services). Patient is homebound because (i.e., "patient has shortness of breath with minimal exertion, requires numerous rest breaks for infrequent absences from home") 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 face-to-face visit encounter that meets the face-to-face encounter requirements with this patient. Date of Face-to-Face Encounter  *Physician Requesting Referral Office Contact Name Office Email 
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