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Home health face to face cheat sheet

Home Health Referral Form / Face to Face Encounter 2026

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The document is a referral form for home health services from Hope Home Health, located in Dublin, CA. It includes sections for patient information, diagnosis, insurance details, and a certification by a physician regarding the medical necessity of various home health services. The form also requires documentation of a face-to-face encounter with the patient and outlines criteria for determining if the patient is homebound.

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Click ‘Get Form’ to open the Home Health Referral Form in the editor.
Begin by entering the 'Date of Referral' at the top of the form. This helps track when the referral was made.
Fill in the 'Patient Name' and 'Date of Birth' fields to ensure accurate identification of the patient.
Provide the patient's 'Address' and 'Phone Number' for contact purposes.
In the 'Diagnosis' section, detail any relevant medical conditions that justify home health services.
Indicate insurance information by checking either Medicare or Private, and fill in the corresponding ID number.
Select all applicable home health services needed by checking boxes next to options like Skilled Nursing or Physical Therapist.
Document the date of your face-to-face encounter with the patient, ensuring compliance with medical requirements.
Describe why the patient is considered homebound by checking appropriate reasons listed on the form.
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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Versions	Form popularity	Fillable & printable
2017	4.1 Satisfied (60 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the purpose of a F2F encounter?

The home health face-to-face (FTF) encounter must occur within 90 days prior to the Start of Care (SOC) or 30 days after the SOC. This tool will assist in assuring the FTF encounter occurs timely. In addition, the following resources are available on the CGS website.

Who can perform a face-to-face encounter?

Observation services, generally, do not exceed 24 hours. Documentation should include: 1. The attending physicians order including clock time for the observation service or clock time can be noted in the nursing admission notes/observation unit notes outlining the patients condition and treatment.

What is the CMS regulation F242?

The face-to-face encounter must be performed by one of the following: The docHubing physician or a physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.

What are the face-to-face rules for Medicare?

The CMS regulation at 483.15, F242 protects the resident(s) right to choose to accept food from visitors, family, friends, or other guests (e.g., facility-sponsored activities such as a community pot luck).

What is the face-to-face timeline for home health?

Physician or qualified providers must document face-to-face encounters with patients and docHub that the patient meets the criteria for home care and has a defined need for homecare services. A face-to-face encounter and homecare certification form must be provided to the homecare agency prior to admission.

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What are the CMS regulations for face-to-face encounters?

The intent of the F2F was to reduce fraud, waste, and abuse by making it a Medicare condition of payment that a physician, or other health care provider, physically meet with patients to assess their specific care needs in person prior to ordering home health services.