PRINT REFERRAL FORM 

Patient Basic Information
Last Name: First Name:
D.O.B:
Patient Address:
City: State: Zip:
Patient Phone Number:
Secondary:
Caregiver:
Relationship:
Phone Number:
Care Plan Oversight
Will the Ordering Physician Sign and Oversee the Plan of Care?
 Yes No If No, which physicain will sign and oversee the paln of care?:
DR:
Patient Insurance
Medicare:
Medicaid:
BXBS:
Other:
Physician Ordering Services
Dr:
Phone:
Fax:
Address:
NPI#
PECOS Registered?  Yes No
Services Ordered Diagnosis
Choose one box with your order for SOC date:
 SOC on a specific
 Within 48 hours of SOC referral
The following services are medically necessary:
 Skilled Nursing  Physical Therapy  Speech Therapy
 Occupational Therapy  Home Health Aide  Social Worker
VERIFICATION OF PHYSICIAN AND PATIENT FACE-TO-FACE ENCOUNTER (MUST BE COMPLETED)
DATE OF PHYSICIAN ENCOUNTER
MEDICAL REASON FOR ENCOUNTER:  
 
CLINICAL FINDINGS:
 
REASON PATIENT IS HOMEBOUND:
(examples: leaving home is a taxing effort, patient is unable to leave home unassisted or due to medical restrictions)
 

Signature of Physician or NPP who performed Face-to-Face encounter and informed certifying Physician if needed:


DATE:
I certify that this patient is under my care and that I have had a Face-to-Face encounter that meets Physician Face-to-Face requrements with the patient noted above.
Content of form based on CMS Calendar Year 2011 Final Rule Face to Face encounter requirments. *NPP- Non Physician Practitioner or clinical Nurse specialist in collaboration with Physician or Physician Assistant under the supervision of the Physicain who will oversee the Plan of Care

 

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