487 DocHub 2026

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4.8 out of 5

123 votes

The document is an addendum to a home care plan, detailing patient information, treatment certification periods, medical updates, and signatures from healthcare providers. It includes sections for patient identification, provider details, and necessary dates.

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Click ‘Get Form’ to open the 487 DocHub in the editor.
Begin by entering the Patient's HI Claim No. in the designated field at the top of the form.
Fill in the Plan of Treatment section, starting with the SOC (Start of Care) date.
Provide the patient's name and ensure it matches official records for accuracy.
Specify the Certification Period by entering both 'From' and 'To' dates.
In the Medical Update section, input the Medical Record No. to maintain proper documentation.
Enter the Provider Name and Provider No. to identify responsible healthcare professionals.
List any relevant Item Numbers as required for your specific case.
Ensure that a Physician's signature is included, along with their date of signing.
If applicable, add an optional name/signature of a Nurse/Therapist along with their date.

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Versions	Form popularity	Fillable & printable
2005	4.8 Satisfied (123 Votes)

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