Request a Visit

Purpose of Request (CMS-Specific)

This request is made solely to obtain an independent face-to-face medical evaluation in accordance with 42 CFR §424.22(a) to determine whether the Medicare beneficiary meets Medicare coverage criteria for home health services, including medical necessity, homebound status (42 CFR §409.42), and need for intermittent skilled services (42 CFR §409.44). No certification or Plan of Care is implied by this request.

Clinical Independence Statement

The evaluating provider shall perform a personally conducted face-to-face encounter, exercise independent medical judgment, and certify services only if Medicare criteria are met. The provider is not required to certify home health services.

Fraud & Abuse Compliance Attestation

No payment, remuneration, incentive, or referral obligation exists or is offered in connection with this request, in compliance with the Anti-Kickback Statute, Stark Law, False Claims Act, and applicable California law.

Patient Freedom of Choice Acknowledgment

The Medicare beneficiary has been informed of their right to choose any qualified provider or home health agency.

Billing & Documentation Responsibility

The evaluating provider may bill Medicare directly for covered services. The home health agency will not prepare or modify clinical documentation.