FACE TO FACE ENCOUNTER - CERTIFICATION ADDENDUM
GENESIS HEALTH SYSTEM
Patient Name
Birth Date
I certify that the face-to-face encounter took place on:
(MM/DD/YY) and is
related to the PRIMARY REASON the patient needs home health services, WHICH
IS:
Medicare Only
I certify that this patient is HOMEBOUND because absence from home requires considerable and taxing
effort DUE TO:
(i.e., limited ambulation, unsteady gait, poor balance, SOB with minimal exertion, mental confusion,
bed or wheelchair bound, needs assist with equipment, etc.)
Physician Signature
Date of Signature
Physician Printed Name
These certification statements are required by the Centers for Medicaid and Medicare Services, and
mandated by the Affordable Care Act (effective 01/01/2011), in order for home health agencies to
provide services to Medicare beneficiaries. These statements are required to be completed by the
physician. Therefore, please fill in the blanks on this form, sign and date it, and return via fax to
Genesis VNA at 563-421-5049.
P:\Forms (Do Not Delete...)GHS\Face-To-Face
Encounter.pdf
Form # 4501503202
Developed 12/10
Revised 07/11