Oxygen & Respiratory Referral Form X/TwitterThis field is for validation purposes and should be left unchanged.Section 1 – Referring ProviderProvider Name(Required)Practice Name(Required)NPI Number(Required)Phone Number(Required)Fax Number(Required)Email Address Section 2 – Patient InformationPatient Name(Required)Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Insurance Name(Required)AddressMember IDSection 3 – Diagnosis InformationPrimary ICD-10 Diagnosis(Required)Secondary ICD-10 DiagnosisSection 4 – Equipment RequestedEquipment Requested(Required) Oxygen Concentrator with Supplies Oxygen Supplies Only Section 5 – Oxygen OrderFlow Rate (LPM)Frequency Continuous Exertion Only Nocturnal Only Section 6 – Length Of NeedLength Of Need(Required) 3 Months 6 Months 12 Months Lifetime (99 Months) Section 7 – Medical NecessityMedical Necessity(Required)Section 8 – Document UploadsClinical Notes(Required)Max. file size: 1 GB. Oxygen Testing Results (Pulse Oximetry or ABG)(Required)Max. file size: 1 GB. Hospital RecordsMax. file size: 1 GB. Discharge SummaryMax. file size: 1 GB. Additional DocumentationMax. file size: 1 GB. Section 9 – Provider CertificationConsent(Required) I certify that I have evaluated this patient and that home oxygen therapy is medically necessary.Electronic Signature(Required)Date Signed(Required) MM slash DD slash YYYY
