* = Required Information
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Home Health Care Dynasty
4640 Lankershim Blvd., #301
Los Angeles, CA 91602
Tel: 877-506-5553
Fax: 310-388-3120
Attn: *

Male Female
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Medicare Patients Only
Face to Face Encounter Acknowledgement- Addendum to Certification

I certify that this patient is under my care and that I, or a nurse practitioner or Physician Assistant working with me, had a face to face encounter with this patient that meets the physician face to face encounter requirements.

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