Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Home Health Certification and Plan of Care Form Template

Streamline Patient Enrollment with Our Care Plan Template

Creating a comprehensive care plan can be overwhelming, but with our Home Health Certification and Plan of Care Form Template, you can simplify the process. This template is designed for home health agencies looking to enroll patients efficiently and ensure compliance with regulations. Benefits include accurate patient documentation, streamlined communication among caregivers, the ability to customize plans to fit individual needs, and enhanced organizational efficiency, making it easier than ever to provide quality home health care. Discover how this template can elevate your agency's workflow.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Primary phone
Email
Residential address (street, city, state, ZIP)
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Please Specify:
Referring/certifying provider full name
NPI number
Practice/organization name
Provider phone
Provider fax
Provider email
Practice address
Face-to-face encounter date (if applicable)
Patient is homebound
Yes
No
Homebound criteria that apply
Please Specify:
Skilled need present
Yes
No
Primary reasons for skilled need
Please Specify:
Primary diagnosis and ICD-10 code(s)
Secondary diagnoses and comorbidities
Recent surgery/procedure date (if applicable)
Functional limitations present
Please Specify:
Precautions
Please Specify:
Overall prognosis
Excellent
Very good
Good
Fair
Guarded
Poor
Unknown
Visit frequency and duration by discipline
Start of care (SOC) date
Plan of care period start date
Plan of care period end date
Disciplines ordered
Skilled nursing (SN)
Physical therapy (PT)
Occupational therapy (OT)
Speech-language pathology (ST)
Medical social work (MSW)
Home health aide (HHA)
Current medications (name, dose, route, frequency)
Medication changes or new orders
Allergies and reactions
Durable medical equipment (DME) and supplies needed
Please Specify:
Wounds present
Yes
No
Wound description and treatment orders
Lab frequency and special instructions
Labs or diagnostics ordered
Please Specify:
Patient-centered goals
Ordered interventions and therapies
Safety measures and education to be provided
Fall prevention education
Medication education
Disease self-management education
Home safety assessment
Emergency plan reviewed
Infection control teaching
Caregiver training
None
Other
Please Specify:
Primary caregiver full name
Relationship to patient
Please Specify:
Caregiver phone
Preferred contact method
Phone call
Text message
Email
Patient portal
Other
Please Specify:
Preferred contact times
Morning
Afternoon
Evening
Weekend
Any time
Primary payer
Medicare
Medicaid
Commercial
Self-pay
Unknown
Other
Please Specify:
Policy or member ID
Authorization number (if applicable)
Authorization or precert obtained
Yes
No
Home health agency name
Agency contact person
Agency phone
Agency fax
Start-of-care clinician name
I certify that the patient is confined to the home and requires intermittent skilled services as outlined above
Yes
No
Physician printed name
Physician signature (type full name)
Signature date
Send a copy of this plan of care to this email (optional)
I authorize the above plan of care and related orders
Yes
No
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Primary phone","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring healthcare forms and templates for home health certification and care planning

When to use this form

Use this form when you admit or recertify a patient for skilled home health. It helps you document the physician order, goals, visit frequency, and safety needs so your team works from one clear plan. Agencies use it at start of care, after a hospital discharge, or when a condition changes and services must be adjusted. Pair it with the Home health care application form to capture patient demographics and insurance at intake. If you staff caregivers, connect assignments through the Home care aide registration form. For visit tracking and proof of service, align the set frequency with the Home care timesheet form. The result: consistent care, cleaner audits, and timely billing.

Must Ask Home Health Certification And Plan Of Care Questions

  1. What is the primary diagnosis and any related conditions?

    This anchors medical necessity and guides which services you order. Clear diagnosis details help the physician certify the plan and support payer review.

  2. Which skilled services are required, how often, and for how long?

    Spelling out discipline, frequency, and duration sets expectations and prevents missed visits. It also ties your schedule to coverage rules and timely outcomes.

  3. Does the patient meet homebound criteria, and what are the clinical reasons?

    Stating specific limitations (e.g., shortness of breath, unsafe ambulation) protects compliance. It gives reviewers a concrete rationale for in-home care.

  4. What are the current medications, allergies, and required equipment or supplies?

    This prevents interactions, supports teaching, and ensures the home has what the patient needs. Listing DME and wound or infusion supplies reduces delays and readmissions.

  5. Who is the certifying physician and what are the certification period dates?

    Accurate contact info enables quick signatures and clarifications. Dates define the episode window, so you can plan recertification before coverage lapses.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel