If the patient requires a modified diet or has other special nutritional or dietary needs, describe:
Please indicate any task, treatments or therapies currently received, or required by the patient:
Does the patient require assistance with, or provision of, skilled tasks (e.g. monitoring of vital signs, dressing changes, glucose monitoring, etc.)?
Yes
No
If Yes, please indicate:
Based on the medical condition, do you recommend the provision of service to assist with skilled tasks, personal care and/or light housekeeping tasks?
Yes
No
Contributing Factors:
Describe contributing factors including but not limited to the social, family, home or medical (e.g. muscular/motor impairments, poor range of motion,
decreased stamina, etc.) situation that may affect the patient’s ability to function, or may affect the need for home care or that may affect the patient's need
for assistance with skilled tasks, personal care tasks and/or light housekeeping. Please include any other information that may be pertinent to the need for
assistance with home care services.
IT IS MY OPINION THAT THIS PATIENT CAN BE CARED FOR AT HOME. I HAVE ACCURATELY DESCRIBED HIS OR HER MEDICAL CONDITION.
NEEDS AND REGIMENS, INCLUDING ANY MEDICATION REGIMENS, AT THE TIME I EXAMINED HIM OR HER. I UNDERSTAND THAT I AM NOT TO
RECOMMEND THE NUMBER OF HOURS OF PERSONAL CARE SERVICES THIS PATIENT MAY REQUIRE. I ALSO UNDERSTAND THAT THIS PHYSI-
CIAN'S ORDER IS SUBJECT TO THE NEW YORK STATE DEPARTMENT OF HEALTH REGULATIONS AT PARTS 515, 516, 517 AND 518 OF TITLE 18
NYCRR, WHICH PERMIT THE DEPARTMENT TO IMPOSE MONETARY PENALTIES ON, OR SANCTION AND RECOVER OVERPAYMENTS FROM,
PROVIDERS OR PRESCRIBERS OF MEDICAL CARE, SERVICES OR SUPPLIES WHEN MEDICAL CARE, SERVICES OR SUPPLIES THAT ARE
UNNECESSARY, IMPROPER OR EXCEED THE PATIENT’S DOCUMENTED MEDICAL CONDITION ARE PROVIDED OR ORDERED.
INCOMPLETE OR MISSING INFORMATION MAY DELAY SERVICES TO THIS PATIENT
Physician’s Signature _________________________________________________________________ Date _________________________
PLEASE SIGN AND RETURN COMPLETED FORM WITHIN 30 CALENDAR DAYS OF EXAMINATION TO:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
New York State Department of Health
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