REFERRAL FORM

Referral Source

Contact Person

Phone

Notes

PROVIDER’S NAME , ADDRESS AND TELEPHONE

Name: Nolimits NYC Home Care Corp.

Address: 74-09 37th Avenue Suite:203B Jackson Heights NY 11372

Phone: 718 616 8690

Fax: 917 830 6387

REFERRING DOCTOR

Physician Name

Address

NPI

License Number

Telephone

Fax

PATIENT INFORMATION

First and last name

Sex
MaleFemale

Tel

Address

City

State

Zip Code

Social Security

Lives with
FamilyAloneCaregiver

DOB

Language Spoken

Family Contratc / Relationship(Must Provide For PRI)

Telephone

Cell

Brief Narrative System: State physical findings from face to face encounters that indicate reason patient is homebound and requires
intermittent skilled nursing services and/or therapy services. this document is an addedum to the initial certification as required by the
Centers for Medicare and Medicaid Services.

INSURANCE

Medicare

Medicaid

Other

FACE TO FACE ENCOUNTER

I certify that this patient is under my care and that I had a face-to-face encounter that meets the Medicare face-to-face encounter requirements with this patient on (insert date that visit occured) :

Face to Face Eencounter related to primary reason for homecare?
YESNO

The encounter with the patient was in whole, or in part for the following medical condition, which is the primary reason for home health care(list medical condition):

I certify that, based on my findings, the following services are medically necessary home health services: (check all that apply):
Skilled NursingPhysical TherapyOccupational TherapySpeech TherapyHHA

To provide the following care/treatments (required only when the physician completing the face-to-face encounter documentation is different than the physician completing the plan of care):

My clinical findings support the need for the above services because

Further, I certify that my clinical findings support that this patient is homebound(i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because

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