Caregiver Support Services

* indicates a required field
Patient Information
Patient Name*

Patient First NamePatient Last Name
Date of Birth*

MonthDayYear
Date
Patient Email
example@example.com
Patient Identifies As

MaleFemale
Language Spoken*
Patient Address*

Street Address

Street Address Line 2

City

Zip Code
City*
State*
State
Zip Code*
Primary Phone Number (Cell Preferred)*
Please enter a valid phone number.
Additional Phone Number
Emergency Contact Name

Emergency Contact First NameEmergency Contact Last Name
Emergency Contact Relationship

Patient Insurance Information
Medicare No.
Medicaid No.
Insurance Name (If not Medicare/Medicaid)
Policy No.
Subscriber Name
Subscriber Name (if Other)
Secondary Insurance Information
Secondary Insurance Name
Secondary Insurance Policy No.
Name of Secondary Insurance Policy Holder

Home Care Orders (required, please select at least one option below)*

HospiceInfusionBehavioral HealthAssess & Instruct for Meds & DiseaseWound CareAssess for Home Health AideOther
Other*
Would you like to supply your own wound care orders?

YesNo
VNS Health Standard Wound Care Protocol will be applied.
Wound Location/Type (if available)
Past Medical History/Comorbidities
Home Care Diagnosis*
Requested Start of Care Date*

MonthDayYear
Date
File Upload

Cancelof

Face to Face Encounter (FFE)
The FFE must occur within 90 days prior or 30 days after the VNS Health Start of Care date.
Physician or Practitioner (NP/PA) Encounter Date*

MonthDayYear
Date
Title of Encountering Provider
Name of Encountering Provider*

What is the definition of being homebound?
“Homebound” means a patient is unable to leave home without considerable and taxing effort.
Patients who leave home infrequently for short durations or for health care MAY STILL be considered homebound. These situations may include (but are not limited to):
- Attending a religious service
- Going to get a haircut
- Walking around the block
- Attending a family event, funeral, graduation or other unique event
- Receiving outpatient kidney dialysis
- Receiving outpatient chemotherapy or radiation therapy
In a brief narrative form, physician’s documentation should always reflect how/why the patient is homebound and requires skilled services. (Example includes: Patient has diminished strength secondary to CVA, has an unsteady gait and needs assistance to ambulate.)

Face-to-Face Certification
Please choose your certification type:*

FOR HOME HEALTH SERVICE UNDER MEDICARE/MANAGED CAREFOR HOME HEALTH SERVICE UNDER MEDICAID
This patient needs nursing care, physical therapy and/or speech therapy and additionally may need occupational therapy that is medically necessary. This patient is under my care. A plan of care has been established and will be reviewed periodically by a physician. A face-to-face encounter occurred no more than 90 days prior or 30 days after the start of home health and was related to the primary reason the patient requires home health services; the encounter was performed by a physician or allowed non-physician practitioner on the encounter date entered earlier on this form.
This patient is confined to the home and needs intermittent skilled nursing care, physical therapy and/or speech therapy, and additionally may need occupational therapy. The patient is under my care. A plan of care has been established and will be reviewed periodically by a physician. A face-to face encounter occurred no more than 90 days prior or 30 days after the start of home health and was related to the primary reason the patient requires home health services; the encounter was performed by a physician or allowed non physician practitioner on the encounter date entered earlier on this form.
I Certify That: I am a Medicare PECOS enrolled physician and I certify that:
This patient needs nursing care, physical therapy and/or speech therapy and additionally may need occupational therapy that is medically necessary. This patient is under my care. A plan of care has been established and will be reviewed periodically by a physician. A face-to-face encounter occurred no more than 90 days prior or 30 days after the start of home health and was related to the primary reason the patient requires home health services; the encounter was performed by a physician or allowed non-physician practitioner on the encounter date entered earlier on this form.

Physician Certification
Physician Name

Physician First NamePhysician Last Name
Physician Address
Physician Phone
Please enter a valid phone number.
If you would like an acknowledgement of this referral, please enter your email below.
Physician Email
example@example.com
Physician Signature*

Clear
Physician Signature Date*

MonthDayYear
Date
Electronic Signature Authorization
By selecting this checkbox, you are authorizing that you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting this checkbox using any device, means or action, you consent to the legally binding terms and conditions of this Agreement.
Should be Empty:

Patient Information

Patient Insurance Information

Secondary Insurance Information

Face to Face Encounter (FFE)

What is the definition of being homebound?

Face-to-Face Certification

Physician Certification

If you would like an acknowledgement of this referral, please enter your email below.