Cms 485 – Fill Out and Use This PDF

Updated: Nov 10, 2026

The CMS-485 form is a crucial document utilized in the home health care process, serving as both a certification and a plan of care for patients. This form outlines essential details such as the patient's medical history, ongoing treatments, and specific care requirements. For those responsible for filling out this form, it is vital to ensure accuracy and completeness to facilitate proper care and Medicare billing.

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Cms 485 PDF Details

In navigating the labyrinth of healthcare documentation, the CMS 485 form stands as a critical instrument for ensuring that patients receiving home health services are accorded the necessary care tailored to their unique health conditions. Mandated by the Department of Health and Human Services and approved by the Centers for Medicare & Medicaid Services, this form, formally titled "Home Health Certification and Plan of Care," serves a pivotal role in the Medicare system. It captures comprehensive details ranging from the patient's personal information, medical diagnosis, to the prescribed medications and treatment plans, thereby laying the groundwork for personalized patient care. Central to this process is the certification or recertification of the patient’s eligibility for home health services under Medicare, stressing the requirement for home confinement and the need for skilled nursing care, physical, speech, or occupational therapy. Beyond its function as a tool for healthcare delivery, the form also acts as a safeguard, ensuring that the information provided is true and accurate under the penalty of law, thereby upholding the integrity of federal healthcare benefits. With privacy considerations taken into account, the CMS 485 encapsulates the essential elements of home health care planning, serving as both a directive for care and a document of legal and ethical significance.

Question	Answer
Form Name	Cms 485
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	home health certification and plan of care, 485 form home health, cms 485 plan, cms 485

How to Fill Out Form CMS-485

Form CMS-485 at a glance

What it is: Form CMS-485 (12-14), OMB No. 0938-0357, is the Home Health Certification and Plan of Care; the primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals.

Who signs: Box 27 is the Attending Physician's Signature and Date Signed.

A filled-in Form CMS-485 example: a nurse completes a plan of care

Form CMS-485 example filled out, example: a nurse completes a plan of care — A home health nurse at Sample Home Care completes this plan of care. Jane Sample is a patient whose certification period runs from 01/04/2027 to 03/04/2027. Her Start Of Care Date is the first day of that period. She had surgery on 12/10/2026 and her diagnoses are dated 12/20/2026. Her functional limitation is Ambulation, her activity permitted is Up As Tolerated and she uses a Walker. She is Oriented and her prognosis is Good, so those boxes are ticked. Nothing goes in the other boxes of Functional Limitations, Activities Permitted, Mental Status and Prognosis because the story names only five. The physician signs on 01/05/2027 and the agency received the signed plan of care on 01/07/2027. The picture shows the form filled in, and its names and figures are sample values.

How to fill out Form CMS-485, box by box

Patient's HI Claim No., Start Of Care Date and Certification Period

Enter the Patient's HI Claim No. in box 1, the Start Of Care Date in box 2 and the Certification Period From and To in box 3 (Form Approved OMB No. 0938-0357).

Enter the Medical Record No. in box 4 and the Provider No. in box 5.

Patient's Name and Address and Provider's Name, Address and Telephone Number

Enter the Patient's Name and Address in box 6.

Enter the Provider's Name, Address and Telephone Number in box 7.

Date of Birth, Sex and Medications

Enter the Date of Birth in box 8 and the Sex, M or F, in box 9.

Box 10, Medications, is for Dose/Frequency/Route, with (N)ew or (C)hanged.

ICD Principal Diagnosis, Surgical Procedure and Other Pertinent Diagnoses

Box 11 is the ICD Principal Diagnosis, with its Date.

Box 12 is the ICD Surgical Procedure, with its Date.

Box 13 is the ICD Other Pertinent Diagnoses, with its Date.

DME and Supplies, Safety Measures, Nutritional Req. and Allergies

Box 14 is DME and Supplies.

Box 15 is Safety Measures.

Box 16 is Nutritional Req., box 17 is Allergies, box 18.A is Functional Limitations and box 18.B is Activities Permitted.

Functional Limitations, Activities Permitted, Mental Status and Prognosis

Box 18.A Functional Limitations: 1 Amputation, 2 Bowel/Bladder (Incontinance), 3 Contracture, 4 Hearing, 5 Paralysis, 6 Endurance, 7 Ambulation, 8 Speech, 9 Legally Blind, A Dyspnea With Minimal Exertion and B Other (Specify).

Box 18.B Activities Permitted: 1 Complete Bedrest, 2 Bedrest BRP, 3 Up As Tolerated, 4 Transfer Bed/Chair, 5 Exercises Prescribed, 6 Partial Weight Bearing, 7 Independent At Home, 8 Crutches, 9 Cane, A Wheelchair, B Walker, C No Restrictions and D Other (Specify).

Box 19 Mental Status: 1 Oriented, 2 Comatose, 3 Forgetful, 4 Depressed, 5 Disoriented, 6 Lethargic, 7 Agitated and 8 Other.

Box 20 Prognosis: 1 Poor, 2 Guarded, 3 Fair, 4 Good and 5 Excellent.

Orders for Discipline and Treatments and Goals

Enter the Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) in box 21 and the Goals/Rehabilitation Potential/Discharge Plans in box 22.

Signatures, Physician and Date of HHA Received Signed POT

Box 23 is the Nurse's Signature and Date of Verbal SOC Where Applicable.

Enter the Physician's Name and Address in box 24.

Enter the Date of HHA Received Signed POT in box 25.

By signing you certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy, and the Attending Physician's Signature and Date Signed go in box 27.

Box 27 is the Attending Physician's Signature and Date Signed.

More rules for Form CMS-485

The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Common questions about Form CMS-485

What is a 485 form in home health?

Form CMS-485 (12-14), OMB No. 0938-0357, is the Home Health Certification and Plan of Care; the primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.

Is there a penalty?

Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Sources

[1] Form CMS-485 (12-14), Home Health Certification and Plan of Care, Centers for Medicare & Medicaid Services (the Official source link on this page).