Page 1 - Referral form 929
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HOME HEALTH SERVICES

                                                                             COMMUNITY REFERRAL
                                                                          and FACE-TO-FACE FORM


         PATIENT INFORMATION
                                                                ( ) Male  ( ) Female
        LAST NAME:           FIRST NAME:                 SEX:                       TELEPHONE:
                                                                                        ( ) Family  ( ) Alone  ( ) Caregiver
        ADDRESS:                   CITY:        STATE:     ZIP CODE:           LIVES WITH:

        SOCIAL SECURITY:                                   DATE OF BIRTH:            LANGUAGE SPOKEN:

        FAMILY CONTACT / RELATIONSHIP (Must  Provide for  PRI)  TELEPHONE:           CELL:

         INSURANCE                                         DIAGNOSIS


        MEDICARE:
        MEDICAID:

        OTHER:
         MEDICATIONS / DOSE / FREQUENCY / ROUTE






                                            n
          I, a Medicare-enrolled physician, or a  4     on-physician practitioner* (CHECK ONE). Had a face-to-face encounter with the
        above-named patient on                for the following  medical condition(s)
                                (Date of Encounter)
                                                          which is related to the primary reason the patient needs  home care.
        The following clinical finding s support that the patient is HOMEBOUND (homebound means that there exist a normal inability to leave
        home, and consequently, leaving home requires considerable and taxing effort) and that the patient needs intermittent skilled nursing
        and / or therapy (physical or occupational therapy or speech pathology):
        HOMEBOUND DUE TO:

        SKILLED NEED:
        (  ) RN                                          (  ) ST
        (  ) PT                                          (  ) MSW
        (  ) OT                                          (  ) HHA
        PHYSICIAN SIGNATURE :                                        DATE:


         MD OFFICE CONTACT                                REFERRING DOCTOR


        NAME:
                                                         PHYSICIAN NAME:
        PHONE:              FAX:                         NPI:                   LICENSE NUMBER:

                                                         ADDRESS:              CITY:       STATE:  ZIP:

                                                         TELEPHONE:                 FAX:
         ‘Per CMS regulations (42 C.F.R §424.22).*the physician responsible for performing the initial certification must document that the face to face patient encounter, which is related to the primary reason the patient requires home health
         services, has occurred.’  This documentation must include the ‘date of the encounter, an explanation of why the clinical findings of such encounter support that the patient is HOMEBOUND and in need of either intermited skilled nursing or
         therapy services as defined in § 409.42 (a) and (c)  ™
         “ a non physician practitioner includes a nurse practitioner, clinical nurse specialist working,in collaboration with the physician, a certified nurse midwife or a physician assistant under the supervision of the physician.
         175 SOUTH 9TH  STREET   |  BROOKLYN, NY 11211  |  Phone number- 718-218-8991 x431  |  Fax number- 929-232-3531  |  referrals@nphny.com
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