Referrals

Patient Basic Information


Patient Insurance


Physician Ordering Services


PECOS Registered?

Care Plan Oversight


Will the Ordering Physician Sign and Oversee the Plan of Care?
If No, which physicain will sign and oversee the paln of care?

Services Ordered


Choose one box with your order for SOC date
The following services are medically necessary

Diagnosis

VERIFICATION OF PHYSICIAN AND PATIENT FACE-TO-FACE ENCOUNTER (MUST BE COMPLETED)


DATE OF PHYSICIAN ENCOUNTER
Signature of Physician or NPP who performed Face-to-Face encounter and informed certifying Physician if needed:
I certify that this patient is under my care and that I have had a Face-to-Face encounter that meets Physician Face-to-Face requrements with the patient noted above.
Content of form based on CMS Calendar Year 2011 Final Rule Face to Face encounter requirments. *NPP- Non Physician Practitioner or clinical Nurse specialist in collaboration with Physician or Physician Assistant under the supervision of the Physicain who will oversee the Plan of Care