HOME OXYGEN EQUIPMENT - LIQUID OXYGEN SYSTEM - RENTAL

GENERAL NOTES PRE-AUTHORIZATION REQUIRED UNLESS OTHERWISE INDICATED. COMMAS APPEARING IN THE "PRESCRIBER REQUIRED" AND "RECOMMENDER REQUIRED" COLUMNS INDICATE OR, EG. "MD", "RN" MEANS MD OR RN. WHERE A REQUIRED PRESCRIPTION IS INDICATED: A CURRENT PRESCRIPTION IS REQUIRED AND BE VALID ONE YEAR AFTER THE DATE WRITTEN. WHERE REGISTERED POLYSOMNOGRAPHIC TECHNOLOGIST (PG), REGISTERED NURSE (RN) OR LICENSED PRACTICAL NURSE (LP)/REGISTERED PRACTICAL NURSE (RO) ARE INDICATED AS A REQUIRED RECOMMENDER, THE RECOMMENDER MUST BE WITHIN THEIR SCOPE OF PRACTICE IN THEIR PROVINCE/TERRITORY. WHERE A REQUIRED RECOMMENDER IS INDICATED, A REPORT MUST BE SUBMITTED AND INCLUDE: A. DIAGNOSIS B. FOR PAP THERAPY: TESTING/TRIAL RESULTS CONFIRMING IMPROVEMENT IN CLIENTS SLEEP CONDITION FOR PAP THERAPY (BASED ON A MINIMUM 30-DAY TRIAL PERIOD) FOR OXYGEN THERAPY: ALL FINDINGS FROM THE RESPIRATORY ASSESSMENT, INCLUDING VITAL SIGNS, INSPECTION FINDINGS, PALPATION FINDINGS, AUSCULTATION FINDINGS, OXYGEN RATE, AND/OR ANY OTHER RELEVANT INFORMATION. C.MODEL TYPE AND QUOTE OF REQUESTED ITEMS D. SIGNATURES WITH DESIGNATION FOR ONGOING RENTAL AGREEMENTS, IF DETERMINED THE EQUIPMENT RENTAL HAS/WILL RESULT IN PAYMENTS EXCEEDING THE PURCHASE PRICE, THE RENTAL AGREEMENT SHOULD, WHERE POSSIBLE AND WHEN DETERMINED APPROPRIATE UNDER THE CIRCUMSTANCES, BE TERMINATED AND THE EQUIPMENT PURCHASED. THE RENTAL FEE OF THE SYSTEM IS TO BE DEDUCTED FROM THE PURCHASE PRICE (IF APPLICABLE). PROVIDERS MUST SUPPLY TRAINING ON THE SAFE USE OF OXYGEN THERAPY AND RESPIRATORY EQUIPMENT AND ENSURE THAT THE CLIENT CONTINUES TO USE THE EQUIPMENT PROPERLY DURING FOLLOW-UP APPOINTMENTS. A BENEFIT NOT LISTED IN THE BENEFIT GRID MAY BE CONSIDERED BY EXCEPTION WITH MEDICAL JUSTIFICATION. SPECIAL NOTES NOTE 17 - FOR EXTENSION OF THE INITIAL OXYGEN THERAPY AUTHORIZATION, THE PROVIDER MUST COMPLETE A 4 MONTH FOLLOW-UP AND SUBMIT AN RRT REPORT TO CONFIRM THE CLIENT CONTINUES TO MEET APPROVAL CRITERIA. NOTE 18 - FOR RENEWAL OF OXYGEN THERAPY, THE PROVIDER MUST COMPLETE AN ANNUAL FOLLOW-UP. A NEW PRESCRIPTION AND AN RRT REPORT ARE REQUIRED TO CONFIRM THE CLIENT CONTINUES TO MEET APPROVAL CRITERIA.