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Physician Progress Note for Face to Face Encounter and
Certification of Eligibility for Home Health Services
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10/15 MC 1537
(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:
Objective information (physical exam findings, test results,
progress/lack of progress, functional losses):
______________________________________________________________
______________________________________________________________
______________________________________________________________
Subjective information:
______________________________________________________________
______________________________________________________________
______________________________________________________________
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 _____________________________________________________________________________
q Pain with activity which limits _________________________________________________________________________________________
q Shortness of breath develops after ambulating short distances and requires frequent rest periods
q Cognitive deficits which impairs orientation, judgment, or decision making
q Develops chest pain with exertion related to ____________________________________________________________________________
q Recent surgery has activity restrictions: ________________________________________________________________________________
q It is medically contraindicated for the patient to leave home because: ____________________________________________________
q Patient is bedbound because __________________________________________________________________________________________
q ______________________________________________________________________________________________________________________
Because of the conditions cited above, one or more of the following types of assistance to leave home is normally required:
q Assistance of another person is required for the patient to safely leave the home
q Supportive Devices are required to safely leave the home: q Cane q Walker q Wheelchair q Crutches
q Special Transportation is required to leave the home: q Transport Van q Ambulance