Home Health Referral Form / Face to Face Encounter 2026

1. Click ‘Get Form’ to open the Home Health Referral Form in the editor.
2. Begin by entering the 'Date of Referral' at the top of the form. This helps track when the referral was made.
3. Fill in the 'Patient Name' and 'Date of Birth' fields to ensure accurate identification of the patient.
4. Provide the patient's 'Address' and 'Phone Number' for contact purposes.
5. In the 'Diagnosis' section, detail any relevant medical conditions that justify home health services.
6. Indicate insurance information by checking either Medicare or Private, and fill in the corresponding ID number.
7. Select all applicable home health services needed by checking boxes next to options like Skilled Nursing or Physical Therapist.
8. Document the date of your face-to-face encounter with the patient, ensuring compliance with medical requirements.
9. Describe why the patient is considered homebound by checking appropriate reasons listed on the form.
10. Complete any special orders and provide your signature along with your name, NPI number, office address, and contact details before submitting.

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