Medicare home health agencies use this plan-of-care layout to put a patient's orders, diagnoses, functional limits and goals for a certification period in front of the certifying practitioner. The agency drafts it; the physician or allowed practitioner reviews the orders and signs the statement that the patient is homebound and needs intermittent skilled care. The agency keeps the signed copy, which must be in place before it bills.
The home health agency fills in items 1 to 25 from its assessment and the referral, and a nurse signs item 23 when care starts on verbal orders. The certifying physician or allowed practitioner (nurse practitioner, clinical nurse specialist or physician assistant) reviews the orders and signs and dates item 27.
The agency enters the patient's claim number, start of care date, certification period (from and to), medical record number, provider number, patient name and address, agency name and contact details, date of birth and sex. Check that the certification period matches the dates you are certifying; a certification may cover less than 60 days but never more.
Item 10 lists each medication with dose, frequency and route, flagged (N)ew or (C)hanged. Items 11 to 13 carry the principal diagnosis, any surgical procedure and other pertinent diagnoses, each with a date; the printed labels still say ICD-9-CM. Compare the medication list with your own records, because signing the plan authorizes the orders on it.
These items list the equipment and supplies the patient needs, safety measures, nutritional requirements and allergies. The agency drafts them from its comprehensive assessment of the patient. Medicare requires the plan to specify the services needed to meet the patient-specific needs that assessment identified, so confirm these entries reflect the patient you saw.
Item 18.A checks functional limitations such as amputation, incontinence, contracture, hearing, paralysis, endurance, ambulation, speech, legal blindness or dyspnea with minimal exertion. Item 18.B records activities permitted, from complete bedrest to no restrictions, including crutches, cane, wheelchair or walker. Item 19 marks mental status and item 20 the prognosis, from poor to excellent. Together they support the homebound and skilled-need statements you certify.
Orders must name each discipline and the type of service, with frequency and duration, for example skilled nursing 3 times a week for 4 weeks for wound evaluation and dressing changes. A range of visits is allowed, and the upper limit counts as the ordered frequency. 'As needed' or PRN orders must describe the signs and symptoms that would prompt a visit and cap the number of such visits.
Enter patient-specific goals, rehabilitation potential and discharge plans. When therapy is ordered, Medicare requires measurable treatment goals tied to the patient's illness or injury and resulting impairments, the expected duration of therapy, and a course of treatment consistent with the qualified therapist's assessment, set by the practitioner after any needed consultation with the therapist.
When care starts on a verbal order, the nurse signs and dates item 23. Item 24 identifies the certifying practitioner by name and address, and the agency records in item 25 the date it received the signed plan of treatment. If a hospital practitioner certifies but will not follow the patient after discharge, the community practitioner who will must be identified.
Item 26 is the certification that the patient is confined to the home, needs intermittent skilled nursing, physical therapy or speech therapy or continues to need occupational therapy, is under your care, and that you authorized the plan and will review it periodically. Sign and date item 27. Item 28 warns that misrepresenting or concealing information required for payment of federal funds may bring a fine, imprisonment or civil penalty.
Download the current version from the source each time; forms change without notice.
Home Health Certification and Plan of Care
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. Medicare lets allowed practitioners, meaning nurse practitioners, clinical nurse specialists and physician assistants, certify and recertify home health eligibility, order services, and establish and review the plan of care, just as physicians can. They must practice within their state's law. The 'Attending Physician's Signature' label in item 27 predates this change.
Each certification period covers up to 60 days. The plan of care must be reviewed and signed by the practitioner who established it at least every 60 days, with each review dated. Any change to the plan, and any new service or increased frequency during the period, needs a written or verbal order before it is provided.
Yes, on a verbal order. A registered nurse or qualified therapist records the order and signs and dates it with the date received. The physician or allowed practitioner must then countersign and date the verbal orders, and sign the plan of care, before the agency bills the final claim for the period.
The 1994 form has no field for it, but the certification must cover it: the certifier attests that a related face-to-face encounter happened within 90 days before or 30 days after the start of care and documents the encounter date. The clinical note of that encounter must be in the certifying practitioner's or the discharging facility's record.