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Run: Hospice Face-to-Face Recertification Encounter

Hospice Face-to-Face Recertification Encounter template for documenting the required recertification visit, eligibility findings, and practitioner attestatio...

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Encounter Timing and Benefit Period

Patient Identifier (required)

Enter the minimum necessary patient identifier used by your organization for the audit trail.

Face-to-Face Encounter Date (required)

Date the hospice physician or nurse practitioner completed the encounter.

Benefit Period (required)

Select the benefit period this recertification supports.

Encounter Location (required)

Where the face-to-face encounter occurred.

Other Location Details

Provide details only if 'Other' was selected for the encounter location.

Practitioner Information

Practitioner Name (required)

Enter the name of the hospice physician or nurse practitioner.

Practitioner Role (required)

Select the clinician role for this encounter.

NPI

Optional National Provider Identifier if used by your compliance process.

Contact Information

Optional contact information for follow-up or audit review.

Clinical Findings Supporting Eligibility

Functional Decline Observed (required)

Select all findings observed during the encounter.

Other Functional Decline Details

Describe any additional decline findings not listed above.

Clinical Summary (required)

Briefly summarize the patient’s current condition and why it supports ongoing hospice eligibility.

Findings Support Terminal Prognosis (required)

Confirm whether the encounter findings support a terminal prognosis of six months or less if the disease runs its normal course.

Attestation and Submission

Attestation Statement

I attest that I personally completed the face-to-face encounter and that the documentation accurately reflects the patient’s condition and hospice eligibility review.

Attested By (required)

Enter the name of the practitioner attesting to this documentation.

Attestation Date (required)

Date the attestation was completed.

Documentation Acknowledgment (required)

Confirm that you understand this submission will be stored in the patient record and may be reviewed for compliance and audit purposes.

Yes No N/A

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