Use this form as a sample face-to-face verification and home health assessment:
 
 
Patient Name:___________________________      Patient Birth Date:_____________
 
The Face-to-Face encounter with this patient occurred on:
 
_____________________________________________________________
            Month                         Day                            Year
 
Name of Physician/Nurse Practitioner/PA who performed F2F encounter:
 
__________________________________________________________________
 
Home Health  Admission Summary Information for Home Health Services
 
Date of Home Health Admission:________________________________________                                  
 
The patient was seen by home health for the following medical conditions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 
Home Health skilled services ordered,  and the reason for the services: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 
This patient is homebound because:___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 
I have read and agree with the patient information provided above.   
 
Physician Signature _________________________________  Date _________________
 
Physician Printed Name____________________________________________________
 
 
PLEASE KEEP A COPY OF THIS INFORMATION IN THE PATIENT’S MEDICAL RECORD.