* = Required Information
1. Hospitalist provider conducted the face-to-face encounter and certification.
Date Conducted
Provider's Name:
Copy of face-to-face certification documentation requested/obtain
Yes
No
2. Face-to-face encounter conducted within 90 days of home care SOC.
Date Conducted
Provider's Name:
Copy of face-to-face certification documentation requested/obtain
Yes
No
3. Face-to-face encounter will be conducted within 30 days of home care SOC.
SOC Date:
Date of 30
th
day:
Date of scheduled visit:
Was physycian's office contacted to verify appointment and purpose of appointment?
Yes
No
If
Yes
date contacted:
By Whom:
If
No
explain
Additional Information
Security Code
*