Adult Long Term Oxygen Therapy Assistive Technology Request Form
1. CLIENT INFORMATION
Last Name
Medicare No
First Name
Title
Mr
Mrs
Ms
Date of birth:
Miss
Address
Suburb
Postcode
Phone
Mobile
2. DIAGNOSIS
Interstitial lung disease
Cystic Fibrosis
COPD
Pulmonary Fibrosis
Congenital cardiac disease
Bronchiectasis
Pulmonary Hypertension
Cardiac failure intractable
Other:
3. ELIGIBILITY
Findings required to support
diagnosis
Discharge date from acute care facility:
Date of assessment in room:
/
/
/
OR
/
(if client has not been acutely unwell for ≥ 3 months)
Consumer is a non-smoker/has ceased smoking
Consumer is aware that they will not be eligible for funding if they continue to smoke.
The client’s condition is stable and requires Long Term Oxygen Therapy for management
Yes
No
in the home
Please complete only one of A to C
A.
Prescription is 24 hours (continuous)
Prescription is ≥ 16 hours
Daytime PaO2 ≤ 55mmHg at rest on room air when stable (arterial blood gas results
attached)
B.
Prescription is 24 hours (continuous)
Prescription is ≥ 16 hours
Daytime PaO2 56 – 59mmHg at rest on room air when stable (arterial blood gas results
attached)
PLUS
Documentation of significant end-organ damage due to hypoxia:
pulmonary hypertension
right heart failure
polycythaemia
Other:
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult Long Term Oxygen Therapy Assistive Technology Request Form
C
Prescription is ≥ 6 hours (nocturnal)
Technical and Physician report of sleep study or nocturnal oximetry demonstrating SpO2 ≤ 88%
for more than a third of sleep time (copy attached)
OR
Technical and Physician report of sleep study or nocturnal oximetry demonstrating SpO2 ≤ 80%
for more than 10% sleep time (copy attached)
OR
Technical and Physician report of sleep study or nocturnal oximetry demonstrating hypoxia-related
sequelae (copy attached) with:
pulmonary hypertension
right heart failure
polycythaemia
Other:
PLUS
Technical and Physician report of sleep study nocturnal oximetry demonstrating SpO2
demonstrating improvement on oxygen therapy (copy attached)
4. ELIGIBILITY - PORTABLE OXYGEN (2 x C-Cylinders)
Please complete only one of D to F
D.
Prescription is 24 hours (continuous)
Client demonstrates satisfactory compliance with long term continuous oxygen therapy and
portable oxygen therapy as prescribed
PLUS
Need for portable oxygen is for:
enables greater mobility
break in oxygen therapy results in significant drop in oxygen saturation to dangerous levels
attendance to pulmonary rehabilitation/medical appointments
Other:
PLUS
Client is willing to fund ongoing cylinder refills and delivery charges for the cylinder
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult Long Term Oxygen Therapy Assistive Technology Request Form
E.
Prescription is ≥ 16 hours
Client demonstrates satisfactory compliance with long term oxygen therapy ≥ 16 hours and
portable oxygen therapy as prescribed
PLUS
Endurance test (i.e. 6 minute walk test) demonstrates distance walked improves by ≥ 30% when
on oxygen (results attached)
PLUS
Need for portable oxygen is for:
enables greater mobility
break in oxygen therapy results in significant drop in oxygen saturation to dangerous levels
attendance to pulmonary rehabilitation/medical appointments
Other:
PLUS
Client is willing to fund ongoing cylinder refills and delivery charges for the cylinder
F.
Prescription is < 16 hours
Client demonstrates long term (≥ 12 month) requirement
PLUS
Evidence of daily usage requirement (justification letter attached)
PLUS
Endurance test (i.e. 6 minute walk test) demonstrates distance walked improves by ≥ 30% when
on oxygen (results attached)
PLUS
Documentation supporting the need for portable oxygen (justification letter attached)
PLUS
Client is willing to fund ongoing cylinder refills and delivery charges for the cylinder
5. EQUIPMENT DECISION (SPECIFICATIONS)
Concentrator:
l/min
C Cylinder:
l/min (Portable oxygen criteria addressed)
D Cylinder:
l/min (justification letter attached)
Regulator:
Standard
Conserver
Nasal cannula size:
N.B. for tracheostomy clients, complete requests for HME’s on the respiratory consumables form
Is the recommended equipment compatible with the environment where the consumer
Yes
No
Yes
No
Yes
No
lives?
Has the consumer been made aware that data regarding compliance with therapy will be
collected and reported to the prescriber?
Does the client use any other respiratory equipment?
If Yes, please specify:
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult Long Term Oxygen Therapy Assistive Technology Request Form
6. PLAN FOR IMPLEMENTATION
Which supplier (company) has provided initial oxygen supply to this client?
Delivery address for equipment:
Clients home address
Other, provide details below:
Name:
Address:
Phone:
Fax:
Please ensure the client has received information outlining the following:
-
follow up clinical review arrangements
-
the clients ongoing compliance with therapy responsibilities
-
contact numbers for clinical advice regarding treatment and clinical care
-
client/carer has completed a Consumer Application Form
-
Electricity rebate application is completed, for more information see:
http://www.deus.nsw.gov.au/energy/Information%20for%20Consumers/Energy%20Rebates.asp#P35_
2008
7. PRESCRIBER DECLARATION
Please provide the name, address and contact details of the clinician/Prescriber who will continue to
monitor the client’s condition.
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
DECLARATION
I declare that I have assessed the consumer and have the required qualification and level of experience
to prescribe this equipment according to the Professional Criteria for Prescribers.
Signature:
Date:
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult Long Term Oxygen Therapy Assistive Technology Request Form
8. OTHER CONTACTS
Please provide the contact details of any other relevant health professionals who will continue to be
involved with the management and monitoring of the client’s condition once in the community. The
delegated professional(s) will be included in any correspondence regarding provisions to the client.
Other Contact 1:
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
Other Contact 2:
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
EnableNSW contact details
Email:
enable@health.nsw.gov.au
Post:
EnableNSW
Health Support Services
Locked Bag 5270
PARRAMATTA NSW 2124
Fax:
(02) 8797 6543
If you require assistance or further information to complete this form please
contact EnableNSW at 1800 ENABLE (1800 362 253).
NB: Please ensure all contact details and a completed consumer application form is provided
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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