Oxygen Rental Form

Oxygen Concentrator Rental
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Age:*
Parent or Guardian (if applicable)

First NameLast Name
Phone Number
Please enter a valid phone number.
Alternate or non-US phone number
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Hotel if applicable:
Room #:
Address of place of lodging including room # (if applicable) if not listed above*

Address

Room #

City

Zip Code
Date of Arrival*

MonthDayYear
Date
Date of Departure*

MonthDayYear
Date
DATES OF RENTAL:
Start date:*

MonthDayYear
Date
End date:*

MonthDayYear
Date
Time you will be checking out of your lodging:*

Hour Minutes

AM/PM Option
Allergies to Medications?

No medication allergiesYes - Please List
Current Medications

No medicationsYes - Please List
Are you allergic to any medications?

YES (please list)NO
Medication Allergies:
Are you taking any medications?

YES (please list)NO
Current Medications:
Past or Present Medical Conditions:*

No medical conditionsHeart problemsLung problemsDiabetesPrior Covid infectionHigh Blood PressureHistory of Altitude SicknessThyroid diseaseHistory of High-Altitude Pulmonary EdemaOther (Please List)
Surgeries*

NoneYes (please list)
Family Medical History*

NoneYes (please list)
Social History:
Smoke Cigarettes*

NoneYes (please list # per day)
Drink Alcohol*

NoneYes (please list # of drinks per week)
Recreational Drug Use*

NoneYes (please list type and frequency)
PATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM
Notice of Privacy Practices.

I acknowledge that I have been offered a copy of the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures.

I understand that I may contact the Office Manager if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates.

To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Notice of Privacy Practices
Initial (draw or use mouse)

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Initials (draw or use mouse)
Release of Information

I hereby permit the medical providers or other health professionals involved in the outpatient care to release healthcare information for purposes of treatment, or healthcare operations.
Initial (draw or use mouse)

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Initials (draw or use mouse)
CONSENT TO EMAIL OR TEXT USAGE HEALTHCARE COMMUNICATIONS

I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number AND/OR emails to receive communication. I understand that security of information sent, cannot be guaranteed.

The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

Revocation of the permission to use text and/or email may be done in writing at any time.
Initial (draw or use mouse)

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Initials (draw or use mouse)
My medical information may be shared with (ie: spouse, parent, provider etc.):
Name and phone number
TREATMENT CONSENT AND DISCLOSURE

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment.

By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment through this practice. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any treatment ordered for you. If you have any concerns regarding any treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a Medical Provider (may be a Physician or Nurse Practitioner) or the certified medical designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care with this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

FINANCIAL AGREEMENT

I understand that payment is due at the time of service. I acknowledgment that High Altitude Mobile Physicians does not accept any insurance plans including Medicare and will not bill the insurance company directly. Due to the nature of the service, there are no refunds.

I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
Signature*

Clear
Date*

MonthDayYear
Date
PRIVATE CONTRACT

·       I, Danielle Shook and Leslie Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.

·       I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.

·       I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.

·       I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.

·       I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

·       I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.

·       The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2022.

·       I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

·       This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)

·       I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.
Patient Signature:

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YOUR MEDICAL PROVIDER WILL COMPLETE BELOW. PLEASE CLICK SUBMIT NOW.
Provider Signature:

Clear
Date:

MonthDayYear

Hour MinutesAM/PM Option
Provider note:
O2 sat on room air:
HR on room air:
Note:
Oxygen RX
Oxygen concentrator L/min via cannula, continuous while sleeping. As needed while awake.
Provider Name and NPI#
Provider signature:

Clear
Concentrator #:
Conc. P/U Date:

MonthDayYear
Date
ICD-10 Diagnosis Code*
Other ICD-10 code
Other ICD-10 code
Charges:
prevnext( X )
Oxygen Concentrator Rental
$150.00



Oxygen Concentrator Rental - second
$150.00



Oxygen Concentrator- Extra Cannula(s)
$5.00



Oxygen Concentrator Splitter(s)Splitter, straight tubing and extra cannula
$10.00



Oxygen Concentrator CPAP adapter(s)CPAP adapter, straight tubing
$10.00



Total

$0.00
Other:
Other Amount $:
Other:
Other Amount $:
Total:
Should be Empty:

Oxygen Concentrator Rental

DATES OF RENTAL:

Social History:

PATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM

Provider note: