Face to Face Encounter Form

I certify that this patient is under my care and that I, or a Nurse Practitioner or Physician’s Assistant working with me , had a face-to-face encounter that meets the physician face to face encounter requirement with the patient on:    

The encounter with the patient was in whole, or part, for the following medical condition, which is the primary reason for the Home Health care. (select medical condition);

I certify that, based on my findings, the following services are medically necessary home health services

Nursing  
   Diebetic/Diet Education 
  Saftey assesment/training 
  Pain Management
  Wound Care
  Catheter Changes  
  Injection/infusion  
  Med Management and Teaching   
  

Physical Therapy
 Phys/Home safety assessment
 Gait training
 Therapeutic exercises
 Strengthening exercise
 Assess & instruct on equipment needs
 

Speech Therapy
  Assessement
  Speech Restorative Therapy
  Assess and Instruct of Swallowing

Ocupational Therapy
  Physical/Home safety assessments
  Assess equipment needs and instruct on use

My clinical findings support the need above for the above services because: 

Further, I certify that my clinical findings support that this patient is homebound (ie absences from homerequire conciderable and taxing effort and are for medical reasons of religious services or are infrequent or of short duration when for other reasons) Because:

  Considerable and taxing effort to leave home

  Poor vision restricts pt to home

  Mobility problems- requires assistance

  Illness or injury that restricts ability to leave home

  Neurological disorder that limits movement

  Severe dyspnea

  High risk of falling

  Gait disorder/falling

  Cognitive impairments

  Infection

  Recovery from surgery

Additional Comments

Physician Signature_________________________________________________       Date ___________________

Physician Printed Name

  Other

Name of Non-physician provider who performed the FTF encounter(if not Physician):

Provider printed Name              Other   

Patient Name  

Patient ID                   Date of Birth 

Your agency of choice :
Gunnison Valley Home Care
45 E 100 North P.O. 759    Gunnison Ut. 84634
Phone  435 528-3955 or 800 324-1801    Fax :435 528-2188