Fillable HOME HEALTH CERTIFICATION AND PLAN OF CARE (Medicare & Medicaid)

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HOME HEALTH CERTIFICATION AND PLAN OF CARE (Medicare & Medicaid)

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The HOME HEALTH CERTIFICATION AND PLAN OF CARE (Medicare & Medicaid) form is 1 page long and contains:

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  • 32 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

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Order Number:
HOME HEALTH CERTIFICATION AND PLAN OF CARE
1. Patient's HI Claim No. 2. Start Of Care Date 3. Certification Period
6. Patient's Name and Address 7. Provider's Name, Address and Telephone Number
4. Medical Record No. 5. Provider No.
From: To:
10. Medications:
11. ICD-10
12. ICD-10
Date
Date
13. ICD-10 Date
8. Date of Birth
9. Sex
Principal Diagnosis
Other Pertinent Diagnoses
Surgical Procedure
14. DME and Supplies 15. Safety Measures:
17. Allergies:
16. Nutritional Req.
F
M
Dose/Frequency/Route (N)ew (C)hanged
18.A. Functional Limitations
18.B. Activities Permitted
1
Amputation
5
Paralysis
9
Legally Blind
1
Complete Bedrest
6
Partial Weight Bearing
A
Wheelchair
2
Bowel/Bladder (Incontinence)
6
Endurance
A
Dyspnea With
Minimal Exertion
2
Bedrest BRP
7
Independent At Home
B
Walker
3
Contracture
7
Ambulation
B
Other (Specify)
3
Up As Tolerated
8
Crutches
C
No Restrictions
4
Hearing
8
Speech
4
Transfer Bed/Chair
9
Cane
D
Other (Specify)
5
Exercises Prescribed
19. Mental Status:
1
Oriented
3
Forgetful
5
Disoriented
7
Agitated
2
Comatose
4
Depressed
6
Lethargic
8
Other
20. Prognosis:
1 Poor 2
Guarded
3 Fair
4 Good 5 Excellent
21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
22. Goals/Rehabilitation Potential/Discharge Plans
24.
26.
23. 25.
27. 28. Anyone who misrepresents, falsifies, or conceals essential information
required for payment of Federal funds may be subject to fine, imprisonment,
or civil penalty under applicable Federal laws.
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Physician's Name and Address
Nurse's Signature and Date of Verbal SOC Where Applicable:
Attending Physician's Signature and Date Signed
Date HHA Received
Signed POT
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HOME HEALTH CERTIFICATION AND PLAN OF CARE (Medicare & Medicaid)

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Completed 5 August 2021

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