Face to face page for home heath care 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. Next, input the patient's date of birth in the format MM/DD/YYYY.
4. In the certification section, indicate the date of your face-to-face encounter with the patient. Ensure this date is within 90 days prior to home health start of care or within 30 days after.
5. Detail the medical condition that necessitates home health care referral in the provided space.
6. Check all applicable services that are medically necessary for home health, such as Nursing, Physical Therapy, or Speech Language Pathology.
7. Provide a brief explanation supporting your clinical findings for these services in the specified area.
8. Certify that the patient is homebound by explaining why absences from home require considerable effort.
9. Finally, sign and date the form at the bottom, ensuring your printed name is also included.

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