Jean Moreno

 CERTIFICATION AND RECERTIFICATION 
 Skilled Nursing Facility - Level of Care 
 Physician: William Mccarty 
 Jean Moreno 
 Sep 07, 2018 
 Customer Name 
 Admitting Date 
 7XQ1FD8mK 
 Medicare Number 
 Recertification 
 I certify that continued inpatient skilled care is necessary for the following (must list reason for each 
 of continued need 
 box checked on line below): 
 for inpatient skilled 
 care 
 Occupational therapy 
 Sweet 
 Physical Therapy 
 the 
 Spring 
 Speech Therapy 
 Specify any additional skilled care 7xweek am, Dementia, 
 CAD HTN Syrupi 
 J 
 estimate that the duration of Inpatient Skilled Care will be for 30 days. 
 Date Due: 
 Plans for post-skilled care are: 
 Home Health Agency 
 Home w/ Office Care Long Term 
 12/7/20 
 Care 
 Other: 
 To Be signed on or 
 before 14th day 
 Continued care is for the condition the patient received inpatient hospital care and/or the treatment 
 after admission 
 of conditions that developed or were treated as the result of the hospital stay or SNF. 
 d 
 Aug 26, 2019
 Physician's Signature 
 Signature 
 Revised June, 2012
