Healthcare Oxygen Tanks Document

HEALTHCARE OXYGEN TANKS AGREEMENT AND PATIENT ACKNOWLEDGMENT

Patient Identification

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance & Billing

Prescribed Oxygen Therapy

Prescribing Physician:

Prescription Date:    Flow Rate:

Duration of Therapy:

Cylinder(s) — Size/Qty:

Home Concentrator — Model/Serial:

Portable Oxygen Concentrator — Model/Serial:

Medical History & Precautions

Safety, Use & Maintenance — Patient Acknowledgment

I acknowledge I have received verbal and written instruction on the safe use of oxygen equipment, including but not limited to: no smoking near oxygen; keep equipment at least 5 feet from open flames and heat sources; secure cylinders in upright position; do not use oil, grease, or flammable products on or near oxygen equipment. Initials:

I understand oxygen is a prescription medical therapy. Failure to follow directions may result in personal injury, property damage, or death. I agree to inspect equipment daily and report malfunctions to the provider. Initials:

Yes, patient or caregiver was instructed on cleaning tubing, cannula, humidifier, and filter replacement where applicable.

Risks, Benefits, and Alternatives

The benefits of supplemental oxygen include improved oxygenation, decreased symptoms of hypoxia, and improved exercise tolerance. Known risks include fire hazard, nasal or skin dryness, and rarely oxygen toxicity with excessive flow. Alternatives, risks of no therapy, and expectations have been explained by the prescribing clinician.

By signing below I authorize the provision of the oxygen equipment and agree to follow prescribed instructions. I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

Financial Responsibility & Equipment Ownership

I accept financial responsibility for charges not covered by insurance, including rental, repair charges for damage due to misuse, and replacement of lost accessories. Ownership of equipment (cylinders, concentrators) is indicated by the provider at delivery; patient must not attempt repairs or modify equipment.

HIPAA Authorization for Billing & Communication

I authorize the release of my protected health information necessary to process insurance claims and to communicate regarding equipment delivery, servicing, and billing to the parties listed below. This authorization is voluntary and may be revoked in writing except to the extent action has been taken in reliance upon it.

Authorization Term and Expiration

This authorization to provide oxygen equipment and related services is effective on the date of patient signature below and shall remain in effect until: unless earlier revoked in writing.

Patient Statements & Certification

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I accept responsibility to notify the provider of any changes to my health status, insurance, or residence that may affect delivery or use of oxygen equipment.

I understand I may withdraw this authorization at any time by providing written notice to the provider, except to the extent that actions have already been taken in reliance on my authorization.

Training Verification

The following training topics were provided and demonstrated to the patient or caregiver (check all that apply):
Start/Stop and alarm response   Tubing and cannula replacement  
Cylinder exchange/refill procedures   Emergency procedures and contact numbers

Sign Now