Healthcare Oxygen Certification Document

HEALTHCARE OXYGEN CERTIFICATION DOCUMENT

This Oxygen Certification Document establishes medical necessity, treatment parameters, and patient responsibilities associated with the prescription and use of therapeutic supplemental oxygen. Patient and prescribing clinician information below will be used for clinical records, equipment provisioning, and payer documentation. The patient must review and acknowledge the risks, safety precautions, and consent statements contained herein.

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance and Billing

Policy/ID Number:    Group Number:

Medical History and Clinical Data

Prescribed Oxygen Order (Clinical Parameters)

Primary Diagnosis / Indication:

Oxygen Concentrator    Compressed Oxygen Cylinders    Liquid Oxygen System

Flow Rate (liters per minute):    Continuous or Intermittent: Continuous    Intermittent (hours/day):

Use with Activity (PRN) or Sleep Only: PRN for Activity    Sleep Only

Prescribing Clinician Information and Certification

Clinic or Practice Name:    Phone:

NPI Number:    State License #:

Date of Order:

Clinician Certification: I certify that this patient requires supplemental oxygen therapy as ordered above. The prescribed parameters are based on the clinical evaluation and objective findings documented in the patient's medical record. The equipment and supplies listed are medically necessary for home oxygen therapy and for safety and effective administration of oxygen.

Risks, Safety Instructions, and Patient Responsibilities

Risks and Safety: Oxygen is a medication and a fire hazard when used near open flames, smoking materials, or flammable liquids. Do not smoke or permit others to smoke while oxygen is in use or in the same room as oxygen equipment. Secure cylinders in an upright position. Keep oxygen systems away from heat sources. Failure to follow these instructions can lead to serious injury or death.

Patient Responsibilities: Patient agrees to: (a) use oxygen exactly as prescribed; (b) maintain equipment per provider instructions; (c) notify the prescriber and equipment provider of changes in clinical status; (d) keep equipment and supplies free from hazards; and (e) comply with safety checks and maintenance requirements. The patient accepts financial responsibility for non-covered services and for loss or damage due to misuse.

Fire hazard and no smoking instruction    Equipment operation and alarms    Troubleshooting and emergency procedures

Authorization, Release, and HIPAA Acknowledgment

Authorization for Release of Information: I authorize the release of medical and billing information related to this oxygen therapy to the equipment provider, durable medical equipment supplier, and my insurance payer for the purposes of delivery, billing, and quality assurance. This authorization is limited to information necessary to support the medical necessity and provision of oxygen therapy.

HIPAA Acknowledgment: I acknowledge that I have received or been offered a copy of the provider's privacy practices and that my protected health information may be used and disclosed for purposes of treatment, payment, and healthcare operations as described in applicable privacy practices.

Authorization Expiration: This authorization and certification for oxygen therapy expires on: or upon earlier revocation in writing.

I consent to release relevant medical information to the equipment supplier and payer as necessary for treatment and billing.   

I acknowledge I have been informed of risks, safety precautions, and responsibilities associated with oxygen therapy.

Attestation

Patient Attestation: I certify that the information I have provided in this document is true and accurate to the best of my knowledge. I accept the prescribed oxygen therapy and agree to follow instructions and safety precautions. I understand that failure to follow the prescribed therapy or safety measures may result in discontinuation of services or harm.

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