Send Your Referrals Form

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

Patient Name *

Date of Birth *

Address *

City *

State *

Zip *

Phone *

Cell *

Gender *

Male

Female

Emergency Contact *

Phone *

Medicare Number *

Insurance *

Medicaid Number *

Insurance Number *

Primary Diagnosis *

Secondary Diagnosis *

Referring Physician *

Phone Number *

Medically necessary services ordered: *

Specific Orders *

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.

1. Face to Face Encounter Date *

2. 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): *

3. My clinical findings from the patient encounter support the need for the skilled intermittent services above because: *

4. Further, I certify that my clinical findings from the encounter support that this patient is homebound because: *

Physician Signature *

Date *

Medicare Patients OnlyFace to Face Encounter Acknowledgement- Addendum to Certification

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