Request for Oxygen Equipment

Complete the form below to submit a request for oxygen equipment in accordance with CMS DMEPOS documentation requirements. Ensure that all patient and item details are accurate to support compliance and timely processing.

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Patient Name *

Medical Record Number (MRN)

Date of Birth (DD/MM/YYYY)

Medicare Beneficiary Identifier (MBI)

Order Date (MM/DD/YYYY) *

Item(s) Ordered

• Oxygen Concentrator
• Portable Oxygen
• Nebulizer Compressor
• Accessories / Tubing
• Others

If Other, please specify

Frequency of Use

Liters Per Minute (LPM)

Hours per Day

Brand/Model (if known)

HCPCS Code (if known)

HCPCS Code (if known) *

Medical necessity documented in today’s encounter

• Yes

Supporting documentation available in the patient chart

• Yes

Patient meets one or more of the following criteria

• Chronic obstructive pulmonary disease (COPD)
• Hypoxemia evidenced by testing (e.g., SpO2 ≤ 88%)
• Recurrent obstructive sleep apnea
• Other

If Other, please specify

Practitioner Name

NPI

Signature

Clear Signature

Date of Signature

Additional Compliance Elements

• This item requires a Written Order Prior to Delivery (WOPD)
• Order is compliant with CMS and Health Insurance Provider documentation requirements
• SWO is stored in the medical record prior to DME claim submission

one or criteria

Bill Type Code(s)

Revenue Code(s)

upload your ID card

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Doctor report

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Submit