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Homebound Determination Questionnare

The Agency must assess and address the following homebound criteria to determine if the patient is homebound:
1. Does the patient exhibit an inability to leave home?
2. Does the patient exhibit a considerable, and taxing, effort to leave home?
3. If absences do occur, are the absences infrequent or ofrelatively short duration?
4. If absences do occur, are the absences attributable to the need to receive healthcare treatment orto receive therapeutic, psychosocial, or medical treatment,in an adult day care center?
5. Does the patient require use of an assistive device?
Ask the patient the following questions at start of care and as needed.
Document the patient's responses.
Based on the patient responses, this patient has been determined to be homebound. The patient has been given an explanation and, by signing this form, understands the definition of homebound and agrees to comply with the homebound requirement. The patient understands, and agrees, that once his / her condition changes, and he/she Is able to leave the home more often, for longer periods of time, for non-medical purposes, or begins to drive, he /she will immediately contact the Agency. The patient also understands the Agency must ensure that all Medicare and Medicaid patients are homebound, to qualify for home care services and that the Agency must adhere to all federal regulations, at all times, with no exceptions. Failure to comply with homebound requirements may result in patient liability for payment of services, as allowed by federal law.
Clear Signature
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If the patient does not meet Homebound Criteria, immediately call the Agency office for further instructions.
This field is for validation purposes and should be left unchanged.

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