Fast Track Referral

PATIENT INFORMATION:

PATIENT NAME:

First Last

ADDRESS:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PHONE NUMBER:

DOB:

SOCIAL SECURITY NUMBER:

MEDICARE NUMBER:

PLEASE SEND A COPY OF THE MEDICARE CARD AND ALSO THE INSURANCE CARD IF THE PATIENT HAS PRIVATE INSURANCE

If Primary Insurance Is Private Insurance, Please Fill Sent Copy of Insurance Card

Primary Reason for Home Health Care:

PRIMARY DX:

SECONDARY DX:

ADDITIONAL SUPPORTING DOCUMENTATION: Please include the following

H & P

F2F Encounter Note

Last Visit Note

Medication List

SERVICES NEEDED:

Home Health Care Evaluation

Skilled Nursing

HHA

MSW

ADDITIONAL ORDERS:

CERTIFICATION FOR FACE TO FACE ENCOUNTER

ENCOUNTER DATE AND REASON

I certify that a face to face encounter for this patient was performed on the below date and such encounter was related to the primary reason the patient requires home health services. The encounter was conducted in following manner. By me as the certifying physician, or by a non-physician practitioner under my supervision who communicated findings to me, or by an inpatient physician during an inpatient stay who communicated findings to me, or by a non-physician practitioner under supervision of an inpatient physician who in turn communicated findings to me.

DATE OF FACE TO FACE ENCOUNTER:

CLINICAL FINDINGS SUPPORTING SKILLED NEED AND HOMEBOUND STATUS

I certify that home health services are medically necessary, including either intermittent skilled nursing and/or therapy, and this patient is homebound in that absences from the home require considerable and taxing effort, are infrequent or of short duration or are attributable to the need to receive health care.

CERTIFICATION AND AUTHENTICATION

I certify that this patient meets requirements for home health based on my clinical judgement relating to this patient’s medical condition and, if applicable, clinical findings communicated to me by a non-physician practitioner or inpatient physician who performed the face to face encounter.

CERTIFYING AND COMMUNITY PHYSICIAN TO FOLLOW FOR HOME HEALTH NEED IS:

DATE:

LICENSE# 299991484

PROVIDER# 108175

LICENSE# 299992880

Phone

This field is for validation purposes and should be left unchanged.

(239) 643-9121

info@mpch.org

Office Hours: 8am - 5pm