Home Care Referral Form

Intake Dept.
Direct: (718) 748-7447
Fax: (718) 748-5191

1. Certification and Date of Face-to-Face Encounter
I certify that this patient is under my care and that I, or a nurse practitioner, clinical nurse specialist or physician's assistant workingwith me, had a face-to-face encounter with this patient on:
2. Medical Condition Related to Home Health Services
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for homehealth care:
3. Certification of Medical Necessity
I certify that based on my clinical findings the following services are medically necessary for home care services (fill in all that apply)
4. Certification of Homebound Status
My clinical findings from this encounter support the patient is homebound due to: