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.