Physician oxygen prescription

This form to be completed by physician
Oxygen prescription

Dispense only as written

Contact 833-360-2155 | Fax 800-418-6998 | www.oxygenparts.com
Physician information
Prescribing physician*

First NameLast Name
NPI# *
Physician address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician email*
example@example.com
Physician phone number*
Please enter a valid phone number.
Physician fax number*
Please enter a valid phone number.
Patient information
Client/patient date of birth*

MonthDayYear
Date
Patient full name First Name* Last Name*
Patient phone Area Code* Phone Number*
Client/patient address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client/patient phone number*
Please enter a valid phone number.
Client email address*
example@example.com
Prescription
Portable oxygen concentrators (POCs) have the ability to provide flow up to 9 setting on pulse dose (on demand while breathing through nose). Continuous recommended for use during sleep.
- Small Portable Oxygen Concentrator pulse settings are from 1–3, or 1–6 pulse only. Recomended for ambulation, not recomended for sleep
- Larger Portable Oxygen Concentrators have the ability to produce from .5 to 2-3 LPM continuous flow and provide pulse setting up to (depending on model) 6-10 settings. Recomended for sleep up to 2-3LPM continuous flow, ambulation up to 6-10 setting
Various models produce different flow settings depending on size and make.
- Standard stationary oxygen concnetrators have a flow setting from 1–5 LPM continuous.
- High flow stationary concentrators have flow settings from 2-10 LPM continiuous flow.
Liter per minute (LPM) or pulse dose setting*
Enter in the prescribed liter per minute or pulse setting
Prescribed oxygen usage (Continuous flow recommended for sleep)*

For ambulation pulse dose Portable Oxygen Concentrator, 1–6 pulse setting) Recommended use ambulation, not recommended for sleepFor ambulation and sleep (Continuous flow portable oxygen concentrator up to 2-3 LPM, pulse dose up to 6 or 10 setting (on select models) Recommended for ambulation and sleep up to 2 or 3LPM continuousStandard stationary oxygen concentrator, continuous flow, 1–5 LPMHigh flow stationary oxygen concentrator, continuous flow, 2–10 LPMDynaris Apogee nasal cycle 1–6 pulse dose setting
Length of prescription*
Number of months
Diagnosis code/s*
Provide the diagnosis CPT code/s.
Length of need*
Duration = 99+ unless specified.
Date prescription submitted*

MonthDayYear
Today's Date
Physician signature*
Should be Empty:

This form to be completed by physician

Oxygen prescription

Dispense only as written

Physician information

Patient information

Prescription