ࡱ> q` bjbjqPqP *|::$$$$$$$8....<X.L8F/////222EEEEEEE$"GhIE$2'2222E$$//wE4442$/$/E42E44=$$@// ².2R?87@\E0F?80JG30Jp@0J$@ 22422222EE4222F2222888(.888.888$$$$$$ MEDICARE FORM FOR RE-CERTIFICATION  1. PATIENTS LAST NAME FIRST NAME M.I. 2. PROVIDER No. 3. HICN 4. PROVIDER NAME 5. MEDICAL RECORD # 6. ONSET DATE 7. SOC. DATE 8. THERAPY TYPE: PT 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10. TREATMENT DIAGNOSIS 11. VISITS FROM SOC. 12. FREQ/DURATION (e.g., 3/wk x 4 wks) ) PHYSICIAN VISIT WITHIN THIS PERIOD  Yes No N/A CURRENT PLAN UPDATE, FUNCTIONAL GOALS Specify changes to goals and plan for this billing period. If the same as shown on the HCFA-700 or previous 701 enter same. Enter the short term goals to reach overall long-term outcome. Justify intensity if appropriate. Estimate time-frames to meet goals, when possible. ASSESSMENT/JUSTIFICATION FOR CONTINUATION OF SERVICES/PLAN OF CARE SHORT TERM FUNCTIONAL GOALS (Time Bound/Measurable/Functional)TIME-FRAME ESTIMATE1. LONG TERM FUNCTIONAL GOALS (Outcome- Time Bound/Measurable/Functional)1.  I HAVE REVIEWED THIS PLAN OF TREATMENT AND RECERTIFY A CONTINUING NEED FOR SERVICES. ( N/A ( DC 15. PHYSICIANS SIGNATURE 16. DATE: 14. RECERTIFICATION FROM:( N/A THROUGH: 17. Print/type physicians name: 18. MOST RECENT PROGRESS NOTE Signature (progress note):  19. SIGNATURE (or name of professional, including Prof. Designation) 20. DATE 21. ( CONTINUE SERVICES ( DC SERVICES MEDICARE FORM/END OF THE MONTH 1. PATIENTS LAST NAME FIRST NAME M.I. 2. PROVIDER No. 3. HICN 4. PROVIDER NAME 5. MEDICAL RECORD # 6. ONSET DATE 7. SOC. DATE 8. THERAPY TYPE: PT 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10. TREATMENT DIAGNOSIS 11. VISITS FROM SOC. 12. FREQ/DURATION (e.g., 3/wk x 4 wks)  19. SIGNATURE (or name of professional, including Prof. Designation) 20. DATE 21. ( CONTINUE SERVICES ( DC SERVICES FUNCTIONAL LEVEL: Enter the pertinent progress made through the end of this billing period. Compare progress made to that shown on previous HCFA-701, item 22, or the HCFA-700, items 20 and 21. Date progress when function can be consistently performed or when meaningful functional improvement is made or when significant regression in function occurs. FUNCTIONAL LEVEL (End of billing period)  23. SERVICE DATES FROM:  THROUGH:  DISCHARGE/DISCONTINUE SUMMARY X Physical Therapy ( Occupational Therapy ( Speech Therapy ( Sports Therapy NAME: In: Out: Date of Onset: Medical Record Number: Discharge Date: Date of Initial Treatment: Date of Last Treatment: Diagnosis: Physician:  Treatments attended as scheduled ________ ( Yes ( No Missed ________ treatments EDUCATION OF PATIENT/FAMILY When applicable:YESNONA1. Patient/family involved in treatment goals2. Patient/family verbalized understanding of treatment goals3. Patient/family has been instructed about strategies to reduce with pain If yes, please comment: 4. Patient instructed in exercise program Can accurately demonstrate exercises Given written home exercise program5. Patient/family has been involved in and demonstrated understanding of safe and effective use of medical equipment (splints, braces, walkers, TNS units, etc.)6. Information regarding community resources was provided and discussed with patient/ family7. Patient/family has been informed regarding when and how to obtain further treatment8. Instructions given to patient/family were provided to the organization or individual Responsible for the patients continuing care Please indicate organization: 9. 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