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HOME HEALTH REFERRAL
Patient Demographics

This patient is under my care. I have established a plan of care, and it will be reviewed by the physicians periodically. I have authorized the home health services. I refer to MedSide Healthcare and certify, that based on my findings, the following services are medically necessary

My clinical findings support the need for the following Home Health services:
I certify that this patient is “confined to home” (homebound) based on meeting both of the following criteria:

Criteria 1: Homebound Reason

The aid of supportive devices such as:

Criteria 2:

I certify that this form was completed based on a face-to-face encounter that meets the physician face-to-face requirements. The form was completed by a physician based on a face-to-face encounter or information provided by a nurse practitioner, physician’s assistant, certified nurse midwife, or clinical nurse specialist working in conjunction with the certifying physician or physician who cared for this patient in an acute or post-acute facility.