Face-To-Face Encounter Addendum Form printable pdf download

Patient Name: _____________________________________________________DOB: __________________________

Date of Face-to-Face Encounter: I certify that this patient is under my care and that I, Non-Physician Practitioners or a

Resident working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements

with this patient on:

Month/Day/Year: ______________________________________________

Skilled Services (Narrative)

□ Skilled Nursing for: ____________________________________________

□ Physical Therapy for : __________________________________________

□ SLP for: _____________________________________________________

□ Occupational Therapy for: _____________________________________

□ HHA for: ____________________________________________________

Homebound Assessment

Based on the clinical findings of this encounter, this patient meets the definition of homebound because:

(Note: A patient is considered homebound if absences for home are (1) infrequent in nature (i.e. a walk

around the block, attending a religious service, or a ride in the car) and (2) are short in duration and require a

taxing effort (i.e. requires assistance from another person device).

Leaving home is medically contraindicated due to _________________________________________________ diagnosis,

and there exists a normal inability to leave home and leaving home would require a considerable and taxing effort

because of_________________________________________________________________________________________.

Indicate below if patient requires assistance to leave the home.

The patient needs the aid of  supportive devices, or  special transportation, or  the assistance of another person in

order to leave home.

Clinician Signature ________________________________________ Date _________________________________

Clinician Printed Name ___________________________________________________

Certification for Home Health Services: Based on the above findings, I certify that this patient is confined to the 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 initiated the establishment of the plan of care. This patient will be followed by a physician who will

periodically review the plan of care. My signature indicates review and incorporation into this patient’s medical record.

For Hospitalist/Specialist only { } I understand that this patient will be followed by their community physician.

Physician’s Signature: ________________________________________________ Date: _________________________

Physician’s Printed Name: ___________________________________________________________________________

□

Please fax a copy of this document to be incorporated into the patient record ______________________

Visiting Nurse Association of Boston | VNA Care Network

revised January 2015

Face-To-Face Encounter Addendum Form