Patient Notification of Face-to-Face Home Care Requirement

  • Patient Name
  • Patient ID Number
  • I have received notification that my insurance provider requires face to face visit with my physician (whom agrees that I need home care services) and that I have had that visit either 90 days prior to the start of home care services or 30 days after home care services have begun.

    I understand that I am responsible to meet this requirement in order for my home care services to continue uninterrupted and I understand that if this visit is not conducted, my homecare services may be put on bold and/or I may be discharged from care.

    I also understand that my insurance company may not pay for any visits that have occurred during the time period that this requirement is not met.

  • Patient Signature

  • Date of Signature
    Date Format: MM slash DD slash YYYY