Form DOH-3726 "Home Health Certification and Plan of Treatment" - New York

What Is Form DOH-3726?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2005;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-3726 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-3726 "Home Health Certification and Plan of Treatment" - New York

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HOME CARE
AI485
H O M E H E A LTH C E R TIFIC A TIO N A N D P LA N O F TR E A TM E N T
1. Patient's Identification Num ber
2. SO C Date
3. Certification Period
4. Medical Record
5. Provider No.
From :
To:
6. Patient's Nam e and Address
7. Provider's Nam e and Address
10. Medications: Dose/Frequency/Route (N)ew (C)hanged
8. Date of Birth
9. Sex
M
F
11. ICD-9-CM
Principal Diagnosis
Date
12. ICD-9-CM
Surgical Procedure
Date
13. ICD-9-CM
Other Pertinent Diagnoses
Date
14. DME and Supplies/Nutritional Assessment & Counseling/Lab Test
15. Safety Measures
16. Nutritional Reg.
17. Allergies:
18.B Activities Perm itted
18.A Functional Lim itations
1
Com plete Bedrest
6
Partial W eight B earing
A
W heelchair
1
Am putation
5
Paralysis
9
Legally Blind
2
Bedrest BR P
7
Independent at H om e
B
W alker
2
Bow el/Bladder 6
Endurance
A
Dyspnea W ith
3
Up as Tolerated
8
Crutches
C
No Restrictions
(incontinence) 7
Am bulation
M inim al Exertion
4
Transfer Bed/Chair 9
C ane
D
Other (Specify)
3
Contracture
8
Speech
B
O ther (Specify)
5
Exercise Prescribed
4
Hearing
19. Mental Status
1
Oriented
2
Com atose
3
Forgetful 4
Depressed
5
Disoriented
6
Lethargic
7
Agitated
8
O ther
20. Prognosis
1
Poor
2
G uarded
3
Fair
4
Good
5
Excellent
21. Orders for Discipline and Treatm ents (Specify Am ount/Frequency/Duration)
22. Goals/Rehabilitation Potential/Discharge Plans
23. Verbal Start of Care and Nurse's Signature and Date W here Applicable:
24. Physician's Nam e and Address
25. Date HHA
26
. I
certify
recertify that the above hom e health services are
Received Signed PO T
required and are authorized by m e with a written plan for treatm ent which
will be periodically reviewed by me. This patient is under my care, is
confined to his/her home, and is in need of interm ittent skilled nursing
care and/or physical or speech therapy or has been furnished hom e
health services based on such a need, no longer has a need for such
.
care or therapy, continues to need occupational therapy
27. Attending Physician's Signature (Required on 485 Kept on File in Medical Records of HHA)
Date Signed
DOH-3726 (Rev 12/05)
HOME CARE
AI485
H O M E H E A LTH C E R TIFIC A TIO N A N D P LA N O F TR E A TM E N T
1. Patient's Identification Num ber
2. SO C Date
3. Certification Period
4. Medical Record
5. Provider No.
From :
To:
6. Patient's Nam e and Address
7. Provider's Nam e and Address
10. Medications: Dose/Frequency/Route (N)ew (C)hanged
8. Date of Birth
9. Sex
M
F
11. ICD-9-CM
Principal Diagnosis
Date
12. ICD-9-CM
Surgical Procedure
Date
13. ICD-9-CM
Other Pertinent Diagnoses
Date
14. DME and Supplies/Nutritional Assessment & Counseling/Lab Test
15. Safety Measures
16. Nutritional Reg.
17. Allergies:
18.B Activities Perm itted
18.A Functional Lim itations
1
Com plete Bedrest
6
Partial W eight B earing
A
W heelchair
1
Am putation
5
Paralysis
9
Legally Blind
2
Bedrest BR P
7
Independent at H om e
B
W alker
2
Bow el/Bladder 6
Endurance
A
Dyspnea W ith
3
Up as Tolerated
8
Crutches
C
No Restrictions
(incontinence) 7
Am bulation
M inim al Exertion
4
Transfer Bed/Chair 9
C ane
D
Other (Specify)
3
Contracture
8
Speech
B
O ther (Specify)
5
Exercise Prescribed
4
Hearing
19. Mental Status
1
Oriented
2
Com atose
3
Forgetful 4
Depressed
5
Disoriented
6
Lethargic
7
Agitated
8
O ther
20. Prognosis
1
Poor
2
G uarded
3
Fair
4
Good
5
Excellent
21. Orders for Discipline and Treatm ents (Specify Am ount/Frequency/Duration)
22. Goals/Rehabilitation Potential/Discharge Plans
23. Verbal Start of Care and Nurse's Signature and Date W here Applicable:
24. Physician's Nam e and Address
25. Date HHA
26
. I
certify
recertify that the above hom e health services are
Received Signed PO T
required and are authorized by m e with a written plan for treatm ent which
will be periodically reviewed by me. This patient is under my care, is
confined to his/her home, and is in need of interm ittent skilled nursing
care and/or physical or speech therapy or has been furnished hom e
health services based on such a need, no longer has a need for such
.
care or therapy, continues to need occupational therapy
27. Attending Physician's Signature (Required on 485 Kept on File in Medical Records of HHA)
Date Signed
DOH-3726 (Rev 12/05)