Home Health Certification And Plan Of Care

ADVERTISEMENT

Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0357
HOME HEALTH CERTIFICATION AND PLAN OF CARE
1. Patient’s HI Claim No.
2. Start Of Care Date
3. Certification Period
4. Medical Record No.
5. Provider No.
From:
To:
6. Patient’s Name and Address
7. Provider’s Name, Address and Telephone Number
8. Date of Birth
9. Sex
M
F
10. Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD
Principal Diagnosis
Date
12. ICD
Surgical Procedure
Date
13. ICD
Other Pertinent Diagnoses
Date
14. DME and Supplies
15. Safety Measures
16. Nutritional Req.
17. Allergies
18.A. Functional Limitations
18.B. Activities Permitted
1
Amputation
5
Paralysis
Legally Blind
1
Complete Bedrest
6
Partial Weight Bearing
A
Wheelchair
9
2
Bowel/Bladder (Incontinance)
6
Endurance
Dyspnea With
2
Bedrest BRP
7
Independent At Home
B
Walker
A
Minimal Exertion
3
Contracture
7
Ambulation
Other (Specify)
3
Up As Tolerated
8
Crutches
C
No Restrictions
B
Hearing
Speech
Transfer Bed/Chair
Cane
Other (Specify)
4
8
4
9
D
5
Exercises Prescribed
Oriented
Forgetful
Disoriented
Agitated
19. Mental Status
1
3
5
7
Comatose
Depressed
Lethargic
Other
2
4
6
8
20. Prognosis
1
Poor
2
Guarded
3
Fair
4
Good
5
Excellent
21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
22. Goals/Rehabilitation Potential/Discharge Plans
23. Nurse’s Signature and Date of Verbal SOC Where Applicable:
25. Date of HHA Received Signed POT
24. Physician’s Name and Address
26. I certify/recertify that this patient is confined to his/her home and needs
intermittent skilled nursing care, physical therapy and/or speech therapy or
continues to need occupational therapy. The patient is under my care, and I have
authorized services on this plan of care and will periodically review the plan.
27. Attending Physician’s Signature and Date Signed
28. Anyone who misrepresents, falsifies, or conceals essential information
required for payment of Federal funds may be subject to fine, imprisonment,
or civil penalty under applicable Federal laws.
Form CMS-485 (C-3) (12-14) (Formerly HCFA-485) (Print Aligned)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-485 Home Health Certification And Plan Of Care Form Cms-485 Home Health Certification And Plan Of Care Legal
Answer And Plan Of Care Answer And Plan Of Care Legal
Certification And Report Of Frcp 26f Conference And Disctovery Plan Certification And Report Of Frcp 26f Conference And Disctovery Plan Legal
Plan Of Care For Child Plan Of Care For Child Legal
2010 Individual Plan Of Care (ipoc) / Individual Treatment Plan Template 2010 Individual Plan Of Care (ipoc) / Individual Treatment Plan Template Business
2013 Individual Plan Of Care (ipoc) / Individual Treatment Plan Template 2013 Individual Plan Of Care (ipoc) / Individual Treatment Plan Template Medical
Medical Plan Of Care For School Food Service Medical Plan Of Care For School Food Service Business
Sample Treatment Plan Of Care Template Sample Treatment Plan Of Care Template Medical
Parent's Or Guardian's Authorization For Pupil's Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form Parent's Or Guardian's Authorization For Pupil's Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form Legal
Articles And Plan Of Conversion - Minnesota Secretary Of State Articles And Plan Of Conversion - Minnesota Secretary Of State Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2