Physician Progress Note For Face To Face Encounter And Certification Of Eligibility For Home Health Services Form - Grey

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Physician Progress Note for Face to Face Encounter and
Certification of Eligibility for Home Health Services
(Per Medicare regulations, this form cannot be filled out by the home health agency or anyone with a financial relationship to the
home health agency.)
Patient Name: __________________________________________________ Date of F2F Encounter: __________________ DOB: _________________
Information for Physician/NP/PA Conducting the Visit:
First and Last Name (please print): __________________________________________________________________________________________
Credentials:
q MD/DO/DPM
q NP/PA
q Other: ___________________________________________________________
Medical diagnosis for which face to face encounter was conducted and for which home health care services were ordered:
___________________________________________________________________________________________________________________
Patient Encounter Findings:
Objective information (physical exam findings, test results,
Subjective information:
progress/lack of progress, functional losses):
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Homebound Status:
(Does not apply to Medicaid patients)
Prior to this encounter, the patient was: q Unable to safely leave home independently because of a medical condition
q Was able to leave home with minimal effort but there has been a change
The patient is now confined to the home because of the following medical conditions:
q Arthritis and weakness limits endurance and increases the risks for falls outside the home environment
q Unstable gait and muscle weakness due to _____________________________________________________________________________
q Pain with activity which limits _________________________________________________________________________________________
q Shortness of breath develops after ambulating short distances and requires frequent rest periods
q Cognitive deficits which impairs orientation, judgment, or decision making
q Develops chest pain with exertion related to ____________________________________________________________________________
q Recent surgery has activity restrictions: ________________________________________________________________________________
q It is medically contraindicated for the patient to leave home because: ____________________________________________________
q Patient is bedbound because __________________________________________________________________________________________
q ______________________________________________________________________________________________________________________
Because of the conditions cited above, one or more of the following types of assistance to leave home is normally required:
q Assistance of another person is required for the patient to safely leave the home
q Supportive Devices are required to safely leave the home:
q Cane
q Walker
q Wheelchair
q Crutches
q Special Transportation is required to leave the home:
q Transport Van
q Ambulance
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12/15 MC 2656

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