Home Health Referral Form - Life Path
ADVERTISEMENT
1Home Health Referral Form
& Face to Face Document
(336) 532-0100 Main Office
(336) 532-0516 Referral Fax
Patient Name: ____________________________________________________________ DOB: ______________________
I (MD or DO) attest patient had a face to face encounter on date: __________ by: _______________ (MD, DO, NP or PA)
For the following Diagnoses/Conditions: _________________________________________________________________
Narrative to include clinical findings to support the patient’s homebound status & needs skilled home care services:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Certification of Homebound Status
A
B
C
Criteria: Must Meet
, PLUS
&/or
A.
Normal inability to leave home exists and leaving home requires a considerable taxing effort.
B
. The patient is in need of supportive devices; use of special transportation; or assistance of another
person in order to leave home due to [Check all that apply]:
Limited ambulation
Unsafe ambulation
Falls risk
Mental or Psychiatric condition
Risk of elopement
Pain that restricts mobility
Shortness of breath
Other: ___________________________________
&/OR
C
. Leaving home is medically contraindicated due to [Check all that apply]:
Immunocompromised/High risk for infection
Infected/Draining/Complicated wound
Recent surgery
Physician ordered restrictions:________________________________________________________________
Requiring the following Skilled Services:
Nursing: Skilled Observation & Assessment:
Physical Therapy Evaluate & Treat:
Chronic Disease Management
Fall Prevention
Medication Management
Weakness/Balance
Trach care, Catheter care, IV care
Gait training
Wound Care: ________________________
Functional Maintenance Program
Lab/blood draw orders: ________________
Pain management
Teach/Administer: IV, TPN, injections
Home Safety Assessment
Infusion/TPN Company: ____________________
DME Recommendations
Infusion/TPN Orders: ______________________
Other: ____________________
Other:_________________________________
Social Work Assessment & Interventions:
Occupational Therapy Evaluate & Treat:
Safety/Risk/Abuse/Neglect concerns
Energy Conservation Instruction
Social/Emotional factors
ADL Re-training/Adaptive Equipment
Financial & Community Resources
Functional Maintenance Program
Caregiver issues
Home Safety Assessment
Long Range Planning
UE injury/dysfunction
Home Health Aide: Assistance with Bathing/Dressing
Speech Therapy Evaluate & Treat:
Swallowing Evaluation
Communication
Care Programs:
Dementia Care: Nursing: Observation & Assessment; Occupational Therapy: Evaluate & Treat; Social Work: Evaluate
Based on above findings, I certify that this patient is homebound and needs intermittent skilled nursing care &/or physical
therapy services. 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.
Physician Signature (MD or DO only): _______________________________________________ Date: ______________
Physician Name (Print): ______________________________________________________
Person making referral: ______________________________________________________
*Please Fax:
Revised 1/5/2018
- Demographics
- Last Office Note
- Insurance Card
- History & Physical
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business