Physician Progress
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Physician Progress Note for Face to Face Encounter and Certification of Eligibility for Home Health Services (Per Medicare regulations, this form cannot be filled out by the home health agency or anyone with a financial relationship to the home health agency.) Patient Name: Date of F2F Encounter: DOB: Information for Physician/NP/PA Conducting the Visit: First and Last Name (please print): Credentials: q MD/DO/DPM q NP/PA q Other: Medical diagnosis for which face to face encounter was conducted and for which home health care services were ordered: Patient Encounter Findings: Subjective information: Objective information (physical exam findings, test results, progress/lack of progress, functional losses): Homebound Status: (Does not apply to Medicaid patients) Prior to this encounter, the patient was: q Unable to safely leave home independently because of a medical condition q Was able to leave home with minimal effort but there has been a change The patient is now confined to the home because of the following medical conditions: q Arthritis and weakness limits endurance and increases the risks for falls outside the home environment q Unstable gait and muscle weakness due to
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