Oxygen and Respiratory Program Prior Approval Form

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Renewal __

Section 1: Patient Information (to be completed by Regional Office)

Patient's Surname:
Date of Birth: (DD/MM/YY)
Given Name(s):
Sex: M | F
Band #:
Family #:
Client ID#:

Section 2: Physician Information (to be completed by Physician)

Physician's Name:
License / Billing # :
Telephone #:

Diagnosis:

Complications:

• Cor Pulmonale
• Pulmonary Hypertension
• Secondary Polycythemia, indicate
• Hematocrit % ___________ (OXYGEN ONLY)

Section 3: Client Injury History (to be comp leted by Physician)

Is the benefit requested due to the result of an injury: Yes | No
If yes, please complete the following:

Where did the injury occur: Home | Work | Other
When did the injury occur:

Are any of these expenses covered under any other public or private health care plan: Yes | No

Section 4: Oxygen Prescription (to be comp leted by Physician)

Oxygen low rate, 1pm

• Rest
• Exertion
• Sleep

Number of hrs / day

• Rest
• Exertion
• Sleep

Section 5: Arterial Blood Gas and / or Oxygen Tests (to be comp leted by Physician) (OXYGEN ONLY) Signed and dated oxymetry test must accompany this form if PaO2 is greater than 55mmHg. Future signed and dated oxymetry tests may be requested by FNIHB for assessment. ABG results are required for initial oxygen set up, as well as the three month and one year assessments.

ABGs on room air: Yes | No ~
If no, specify ________% ___________ flowrate.

• Date
• pH
• PaO₂ (mmHg)
• PaCO₂ (mmHg)
• SaO₂

Oximetry (SpO₂) Test Results on Room Air (print outs of oximetry test results,
signed and dated, must accompany this form)

• Rest
  Date:
• Exertion
  Date:
• Sleep
  Date:

Section 6: Benefit Requested (to be completed by Provider)

• Description of Benefit Benefit
• Code
• Qty
• Cost MFR Name MFR Item Code and Class Type

Section 7: Provider Information (to be completed by Provider)

Provider Name:
Provider #:
Telephone # :
Fax#:

I hereby certify that the information in Sections 5 and 6 is true and complete and that the oxygen equipment and information pertaining to that equipment
have been provided to the above named client. The NIHB Program reserves the right to request this form for audit purposes.

Provider Signature:

Date: