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.

Order Details

Please complete the following order information accurately. Select the item(s) being ordered, specify brand/model if known, and indicate the appropriate HCPCS code. If ordering accessories, list them separately.

Item(s) Ordered

Medical Necessity Documentation

Please complete the following details to confirm documentation of medical necessity.

Medical necessity documented in today’s encounter
Supporting documentation available in the patient chart
Patient meets one or more of the following criteria

Prescribing Practitioner Information

Complete the following details to certify the prescribing practitioner’s authorization and compliance for oxygen equipment and nebulizer orders.

Additional Compliance Elements

Please confirm the compliance elements related to this order below:

Additional Compliance Elements

Billing Guidance (Optional)

Please enter any applicable billing information if known:

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