HOME HEALTH CERTIFICATION AND PLAN OF CARE

Order ID #session.agencyid#/#Form.Order_ID#

Patient Details
Patient’s HI Claim No. #Form.Insured_HIC#	Start of Care Date #DateFormat(socDate,"mm/dd/yyyy")#	Certification Period #DateFormat(certFrom,"mm/dd/yyyy")# - #DateFormat(certTo,"mm/dd/yyyy")#	Medical Record No. #Form.Pt_Agy_ID#	Provider No. #Form.Agy_CCN#
Patient’s Name and Address #Form.Pt_First# #Form.Pt_Last# #Form.Pt_Street# #Form.Pt_City#, #Form.Pt_State# #left(Form.Pt_Zip,5)#		Gender #Form.Pt_Gender#	Date of Birth #DateFormat(Form.Pt_DOB,"mm/dd/yyyy")#	Phone Number #Form.Pt_Phone#
		Email #GetPatient.Email#		Primary Language #GetPatient.Pt_language#

Clinical Profile
Provider’s Name #Form.Agy_Name#	Address #Form.Agy_Street# #Form.Agy_City#, #Form.Agy_State# #left(Form.Agy_Zip,5)#	Phone Number #Form.Agy_Phone#
NPI #Form.Agy_NPI#		Fax Number #agencyFax#
Clinical Condition Requiring Homecare: #fmtBr(Form.MD_Clinical_Condition)#	Physician Statement on Homebound Status: #fmtBr(Form.MD_Homebound)#

ICD-10 CM Principal Diagnosis: #principalDx#

Other Pertinent Diagnoses
ICD-10 CM	Description	Medications
#otherICD[i]#	#otherdiagnosis[i]#	#fmtBr(Activemeds)#
		#fmtBr(Activemeds)#

Prognosis
#fmtBr(Form.Prognosis)#

Mental and Psychosocial Status
#fmtBr(Replace(Form.Mental_Status & "", "!", ", ", "ALL"))#

Functional Limitations
#fmtBr(Replace(Form.Functional_Limitations & "", "!", ", ", "ALL"))#

Activities Permitted
#fmtBr(Replace(Form.Activities_Permitted & "", "!", ", ", "ALL"))#

DME & Supplies
#fmtBr(Replace(Replace(Form.DME & "", "!", ",", "ALL"), ",", ", ", "ALL"))#

Safety Measures
#fmtBr(Replace(Replace(Form.Safety & "", "!", ",", "ALL"), ",", ", ", "ALL"))#

Nutrition
#fmtBr(Replace(Replace(Form.Diet & "", "!", ",", "ALL"), ",", ", ", "ALL"))#

Allergies
#fmtBr(Form.Allergies)#

Advance Directives
#fmtBr(GetAssessDet.Advance_Directive)#

Caregiver Status
#fmtBr(caregiverStatus)#

Rehabilitation Potential
#fmtBr(Form.Rehabilitation_Potential)#

DISCHARGE PLAN:
#fmtBr(dischargePlanDisplay)#

Orders for Discipline and Treatment:
#fmtBr(ordersDiscipline)#

SN CAREPLAN
#fmtCareplanFreq(Form.Careplan_SN)#

SN NARRATIVE
#fmtBr(snNarr)#

SN GOALS
#fmtBr(Form.Goals_SN)#

OT CAREPLAN
#fmtCareplanFreq(Form.Careplan_OT)#

OT NARRATIVE
#fmtBr(otNarr)#

OT GOALS
#fmtBr(Form.Goals_OT)#

ST CAREPLAN
#fmtCareplanFreq(Form.Careplan_ST)#

ST NARRATIVE
#fmtBr(stNarr)#

ST GOALS
#fmtBr(Form.Goals_ST)#

PT CAREPLAN #fmtCareplanFreq(Form.Careplan_PT)#	PT NARRATIVE #fmtBr(ptNarr)# PT GOALS #fmtBr(Form.Goals_PT)#
MSW CAREPLAN #fmtCareplanFreq(Form.Careplan_MSW)#	MSW NARRATIVE #fmtBr(mswNarr)# MSW GOALS #fmtBr(Form.Goals_MSW)#
HHA CAREPLAN #fmtCareplanFreq(Form.Careplan_HHA)#	HHA NARRATIVE #fmtBr(hhaNarr)# HHA GOALS #fmtBr(Form.Goals_HHA)#

Signature and Date of Verbal SOC Where Applicable:
Electronically signed by: #GetEmps.Emp_First# #GetEmps.Emp_Last# #GetEmps.Skill_1# #GetEmps.Skill_2# #GetEmps.Skill_3# on #DateFormat(printCompletedDate,"mm/dd/yyyy")#

I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. This patient is under my care, and I have authorized the services on this plan of care and I or another physician will periodically review this plan. I attest that a valid face-to-face encounter occurred (or will occur) within timeframe requirements and it is related to the primary reason the patient requires home health services.
F2F date: #DateFormat(f2fPrintDate,"mm/dd/yyyy")#

Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Certifying Physician or Allowed Practitioner Name and Address #Phys_First# #Phys_Last#
#Phys_Street#
#Phys_City#, #Phys_State# #Phys_Zip#
NPI #Phys_NPI#

Phone Number #Phys_Phone#

Fax Number #Phys_Fax#

Physician’s Signature and Date Signed DIGITALLY SIGNED BY #Form.Digital_Signature#

#Phys_First# #Phys_Last#, #Phys_Credentials#
#DateFormat(f2fPrintDate,"mm/dd/yyyy")# : Date of physician last face-to-face