Healthcare O2 Document

OXYGEN (O₂) THERAPY ORDER AND PATIENT CONSENT

Patient Information

Patient Name:     Date of Birth: 

Phone:     Gender: 

Emergency Contact

Relationship:     Phone: 

Insurance & Billing

Policy Number:     Group Number: 

Medical History

Chronic Respiratory Conditions: 

Current smoker or tobacco user:   Yes     Prior home oxygen use:   Yes

Oxygen Therapy Order (to be completed by ordering clinician)

Clinician Contact (phone/fax):     Diagnosis/ICD-10 (if known): 

Flow Rate (L/min):     Delivery Method:   Nasal cannula     Simple mask     Non-rebreather mask

Humidification Required:   Yes    Supply Type:   Concentrator     Compressed gas cylinder

Therapeutic Target SpO2 Range:     Order Start Date:     Authorization Expiration Date: 

Risks, Benefits, and Alternatives

The patient acknowledges that the clinician has explained the intended benefits of oxygen therapy, including relief of hypoxemia and improved exercise tolerance where applicable. The patient further acknowledges that alternatives to prescribed oxygen therapy, including supplemental treatments, observation without oxygen, and palliative measures, have been discussed where clinically appropriate.

Known risks include, but are not limited to: fire and combustion hazard when oxygen is used near open flame or smoking; nasal or facial skin irritation; drying of mucous membranes; carbon dioxide retention in certain respiratory disorders with excessive oxygen delivery; and equipment malfunction. Serious injury may result from improper storage or use of oxygen equipment.

The patient has had an opportunity to ask questions and understands the explanations provided. The patient understands the right to refuse or discontinue oxygen therapy at any time, except where refusal would place the patient at immediate significant risk and clinician intervention is required.

Patient Responsibilities & Safety Instructions

The patient agrees to abide by safety instructions provided, including: do not smoke or allow others to smoke near oxygen equipment; keep oxygen at least several feet from open flames and heat sources; use electrical devices only as instructed; store cylinders upright and secured; notify the supplier or clinician promptly for equipment problems; and maintain scheduled servicing.

The patient confirms that they have received verbal and written instruction on equipment operation, tubing care, cleaning, and emergency procedures, and that a copy of written home instructions has been offered.

HIPAA & Release of Information

By signing this document the patient authorizes release of relevant medical and insurance information to oxygen equipment suppliers, home health agencies, and payers as necessary for provision of oxygen therapy, billing, and quality review. The patient understands that this authorization is limited to information necessary for these purposes and may be revoked in writing at any time, subject to obligations already incurred.

Acknowledgements and Consents

 I consent to receive oxygen therapy as ordered above.

 I acknowledge that the risks and benefits of oxygen therapy have been explained to me and that I have had the opportunity to ask questions.

 I acknowledge receipt of written home oxygen safety and equipment instructions or a documented offer to provide such instructions.

Liability and Financial Responsibility

The patient understands that insurance coverage for oxygen equipment and supplies varies. The patient authorizes billing to the insurer listed but accepts financial responsibility for charges not covered by insurance, including equipment repair or loss if due to misuse. The patient agrees to cooperate with the supplier and clinician regarding equipment return and maintenance.

Emergency Instructions

In the event of sudden respiratory deterioration (increasing shortness of breath, confusion, severe chest pain, loss of consciousness), call emergency medical services immediately. For equipment failure or leakage, disconnect equipment safely and call the oxygen supplier or clinician immediately.

Provider Verification (for administrative use)

Supplier Contact:     Date Verified: 

Revocation & Expiration

This authorization for treatment and release of information expires on the Authorization Expiration Date specified above or upon earlier written revocation by the patient, except to the extent that action has been taken in reliance on this authorization prior to revocation.

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