Healthcare Providers

FAST TRACK REFERRAL FORM

CMS may request medical records from physicians. Please retain supporting documentation such as d/c summary, labs, last office visit note and medication profile in your medical record.

Please complete and fax the following information (or attach demographics / face sheet) and office visit note to: (978-657-7455).

SKILLED SERVICES / MEDICAL INTERVENTIONS: (Describe services the nurse or therapist will perform in the home, e.g. assess, teach, wound care, gait training.)

CERTIFICATION FOR FACE-TO-FACE ENCOUNTER

I certify this patient is under my care and that I, or a nurse practitioner or PA working with me or physician who cared for the patient in an acute or post-acute facility has a face-to-face encounter related to the primary reason the patient requires home health that meets CMS requirements with this patient on:

Based on the above findings, I certify that this patient is confined to the home and needs intermittent skilled nursing, physical therapy, and/or speech therapy. The patient is under my care and I have initiated the establishment of the plan of care for home health.

OPTIONAL PHYSICIAN DOCUMENTATION

This section is provided for the physician's convinience and record keeping in the event of a Medicare audit.

Notice: the attached communication contains priviledged and confidential information. If you are not intended recipent, DO NOT read, copy, or disseminate the communication. Non-intended repicients are hereby placed on notice that any unauthorized disclosire, duplication, distribution, or taking of any action in reliance on the contents of these material is expressly prohibited. If you have receeived this communication in error, please destroy all pages and contact the sender of Alternative Home Health Care LLC at 978-657-7444

FAST TRACK REFERRAL FORM

CMS may request medical records from physicians. Please retain supporting documentation such as d/c summary, labs, last office visit note and medication profile in your medical record.

Please complete and fax the following information (or attach demographics / face sheet) and office visit note to: (978-657-7455).

SKILLED SERVICES / MEDICAL INTERVENTIONS: (Describe services the nurse or therapist will perform in the home, e.g. assess, teach, wound care, gait training.)

CERTIFICATION FOR FACE-TO-FACE ENCOUNTER

I certify this patient is under my care and that I, or a nurse practitioner or PA working with me or physician who cared for the patient in an acute or post-acute facility has a face-to-face encounter related to the primary reason the patient requires home health that meets CMS requirements with this patient on:

Based on the above findings, I certify that this patient is confined to the home and needs intermittent skilled nursing, physical therapy, and/or speech therapy. The patient is under my care and I have initiated the establishment of the plan of care for home health.

OPTIONAL PHYSICIAN DOCUMENTATION

This section is provided for the physician's convinience and record keeping in the event of a Medicare audit.

Notice: the attached communication contains priviledged and confidential information. If you are not intended recipent, DO NOT read, copy, or disseminate the communication. Non-intended repicients are hereby placed on notice that any unauthorized disclosire, duplication, distribution, or taking of any action in reliance on the contents of these material is expressly prohibited. If you have receeived this communication in error, please destroy all pages and contact the sender of Alternative Home Health Care LLC at 978-657-7444