1. Demographics 2. History & Physical 3. Clinical Notes/ Discharge Summary from date of face-to-face encounter
I certify that this patient is under my care and that I, or a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife working in collaboration with me or under my supervision, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient and the patient is homebound.
The encounter with the patient was directly related to the following medical condition, which is the primary reason for home health care: (choose one)
The following clinical findings support that the patient is homebound and that the patient requires skilled nursing and/or therapy: (mark all that apply)
Statement of Homebound Status: (mark all that apply)
I certify that my clinical findings and the patient’s medical condition supports that this patient is homebound due to:
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