A guide to the Home
Oxygen Order Form
Part A
front cover
Air Products Clinicians Helpline
Telephone: 01270 218050
8.00am-5.00pm, Monday to Friday
(open 24 hours for urgent calls only)
Introduction
During 2012, the National Health Service (NHS) is changing the process of
ordering home oxygen supplies:
1. The Home Oxygen Order Form (HOOF) has changed. HOOF Part A
should be used when the request is made by non specialist Health Care
Professionals (HCPs) or to supply pending a specialist review. HOOF Part
A is restricted to static oxygen equipment only.
2. Ambulatory equipment can only be ordered via a HOOF Part B, completed
by an HCP specialising in home oxygen therapy after the patient has
undergone an oxygen assessment.
3. When completing the HOOF (Part A or B), clinicians can order not only
the flow rate and hours of use but also select the appropriate equipment
to install (namely for HOOF Part A static cylinders and / or static
concentrators)
4. The NHS wishes each new HOOF submitted to now supersede any
previous HOOF for that patient. So it is vital that you ensure each new
HOOF submitted for an existing home oxygen patient fully reflects all the
equipment you wish the patient to have. If you are completing a HOOF
Part A for a patient who currently has ambulatory oxygen equipment,
you may need to refer the patient for specialist oxygen assessment as per
your local care pathway. If you do not wish the ambulatory equipment
to be removed when we process the new HOOF Part A and whilst they
await an assessment you will need to explicitly instruct us on the HOOF
not to remove any previously ordered ambulatory oxygen.
This change has come about as a consequence of two key national
publications, together with the NICE guidance:
1. The Outcomes strategy for people with Chronic Obstructive Pulmonary
Disease (COPD) and asthma in England
2. Home Oxygen Services Good Practice Guide to Assessment and Review
3. National Institution for Health and Clinical Excellence (NICE) Guidelines
ref GC101 (Chronic Obstructive Lung Disease update)
2
A guide to the Home Oxygen Order Form - part A
This booklet
•
•
•
•
•
•
Details how you should order the equipment from us
Explains how to complete the Home Oxygen Order Form (HOOF)
Explains the Home Oxygen Consent Form (HOCF)
Provides information regarding the equipment available
Gives you guidelines on which equipment to order
Explains how the supply and service of the equipment will subsequently
be managed
A guide to the Home Oxygen Order Form - part A
3
How to complete the HOOF
(Part A)
The HOOF Part A should be used where the request is made via non-specialist
HCPs, or for temporary supply pending a specialist review.
Historically, up to 40% of HOOFs have had to be rejected due to critical
missing patient, clinical and prescriber information. Every HCP can
dramatically reduce the number of rejections by simply ensuring that the
form is completed fully and legibly.
The NHS wishes each new HOOF submitted to now supersede any previous
HOOF for that patient. So it is vital that you ensure each new HOOF submitted
for an existing Home Oxygen patient fully reflects all the equipment you
wish the patient to have. If you are completing a HOOF Part A for a patient
who currently has ambulatory oxygen equipment, you will need to refer the
patient for specialist oxygen assessment as per your local care pathway. If
you do not wish the ambulatory equipment to be removed when we process
the new HOOF Part A and whilst they await an assessment you will need
to explicitly instruct us on the HOOF not to remove any previously ordered
ambulatory oxygen.
This guide will take you through each section and help you to complete the
HOOF Part A so that it is right first time.
4
A guide to the Home Oxygen Order Form - part A
The individual sections:
Sections 1 and 2 - Patient and carer details
These require patient and carer information. Please fill in all the boxes,
making sure to include the
NHS
number
any contact telephone numbers.
Home
Oxygen
Order Formand
(HOOF)
Part A (Before Oxygen Assessment – Non-Specialist or Temporary Order)
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
1. Patient Details
1.1 NHS Number*
1.7 Permanent address*
1.9 Tel no.
1.2 Title
1.10 Mobile no.
1.3 Surname*
2. Carer Details
1.4 First name*
2.1 Name
1.5 DoB*
(if applicable)
2.2 Tel no.
 Male
1.6 Gender
 Female
1.8 Postcode*
2.3 Mobile no.
3. Clinical Details
3.1 Clinical Code(s)
3.2 Patient on NIV/CPAP
Home
4. Patient’s Registered GP Information
Part A (Before Oxygen As
4.1 Main Practice name:*
 Yes
 No
All fields marked with a ‘*’ are
4.2 Practice address:
Section
3 - Clinical
details
3.3 Paediatric Order
 Yes  No
1.1 NHS Number*
Complete the clinical coding
to assist in data management
and on-going
4.3 Postcode*
4.4 Telephone no.
1.2 Title
5. Assessment
Service (Hospital
or Clinical care
Service)
Ward
Details
(if
applicable)
reviews
to provide
an integrated
plan for 6.the
patient
where
required.
1.3 Surname*
5.1 Hospital or Clinic Name:
6.1 Name:
1.4 HOOF
First name* Part A.
Clinical
Code
definitions
can
be
found
in
section
14
of
the
5.2 Address
6.2 Tel no.:
6.3 Discharge date:
1.7 Permane
1.5 DoB*
/
/
1.6 Gender
 Male  Female
On
the very rare occasion
where the patient is using
5.3 Postcode:
5.4 Tel no:
3. Clinical Details
NIV/CPAP
or is paediatric patient,
it is recommended 9. 3.1
8. Equipment*
Consumables*
7. Order*
Clinical Code(s)
For more than 2 hours/day it is advisable to select a static concentrator
(select one for each equipment type)
that
you refer
to their
respiratory clinician/ Quantity
3.2 Patient on
NIV/CPAP
 Yes  No
Home
(HOOF)
Litres
/ Min Oxygen
HoursOrder
/ Day Form
Type
Nasal Canulae
Mask
% and Type
Part A (Beforepaediatrician.
Oxygen Assessment – Non-Specialist
Temporary Order)
8.1 Static or
Concentrator
3.3 Paediatric Order
 Yes  No
1.8 Postcode
4.1 Main Pra
4.2 Practice
Back up static cylinder(s) will be supplied as appropriate
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
8.2 Static Cylinder(s)
4.3 Postcode
1. Patient Details
A single cylinder will last for approximately 8hrs at 4l/min

10.1 Standard (3 Business Days)
Male
 Female
Details
 Yes
 No
 Yes
 No
10.2 Next (Calendar)
Dayno.
1.10 Mobile
5.1 Hospital or Clinic Name:
10.3 Urgent (4 Hours)


5.2 Address
Section
4 - Patient’s
GP
information
11. Additional
Patient registered
Information 2.
Clinical Contact (if applicable)
Carer
Details12.
(if applicable)
12.1 Name:
Section 4 needs to contain the details
of the GP with whom
the patient is
2.1 Name
5.3 Postcode:
12.2 Tel Form
no.
12.3 Mobile no.
2.2 Tel Order
no.
Home Oxygen
(HOOF)
registered.
7. Order*
Part A (Before Oxygen Assessment
–no.
Non-Specialist or Temporary Order)
13.
Declaration*
1.8 Postcode*
2.3 Mobile
All fields
marked
a ‘*’ are
mandatory
and the
will be
rejected if not
I declare that the information
given
on this
formwith
for NHS
treatment
is correct
andHOOF
complete.
I understand
thatcompleted
if I knowingly
false
Litres / provide
Min
Hours / Day
4. Patient’s
Registered
GP
Information
information, I may be liable to prosecution or civil proceedings.1.I confirm
that
I am the registered healthcare professional responsible for the
Patient Details
4.1 Main Practice
name:*
information
provided.
I also confirm that the patient has read and signed the Home Oxygen Consent Form.
1.1 NHS Number*
1.7 Permanent address*
1.9 Tel no.
4.2 Practice address:
Name:
Profession:
1.2 Title
1.10 Mobile no.
Signature:
Date:
Referred for assessment:
 Yes  No
1.3 Surname*
2. Carer Details (if applicable)
Fax
back no. or NHS email address for confirmation
/ corrections:
4.3 Postcode*
4.4 Telephone
no.
10.1 Standard (3 Business Days)
1.4 First name*
2.1 Name
5.4 Tel no:
8
For more than 2 hours/da
Type
8.1 Static Concentrator
Back up static cylinder(s) wi
8.2 Static Cylinder(s)
A single cylinder will last for
1

10.2 Next
14. Clinical
Code
6. Ward Details
(if applicable)
Service (Hospital or Clinical Service)
e:
5. Assessment Service (Hospital or Cli
Tel no.
10. 1.9
Delivery
Details*
1.7 Permanent address*
1.5 DoB*
2.2 Tel no. 11. Additional Patient Information
CODE
Condition
CODE
Condition
6.1 Name:
1.6 Gender
Postcode*
2.3 Mobile no.
 Malepulmonary
 Female
1
Chronic obstructive
disease1.8
(COPD)
12
Neurodisability
6.2 Tel no.:
2
Pulmonary
vascular
disease
13
Obstructive
sleep apnoea
syndrome
3.
Clinical
Details
4. Patient’s
Registered
GP Information
6.3 Discharge date:
/
/
3
chronic asthma
Chronic heart failure
3.1 ClinicalSevere
Code(s)
4.1 Main Practice name:* 14
5.4 Tel4 no:
I declare that the information given on this form for NHS trea
Interstitial lung disease
15
Paediatric interstitial lung disease
3.2 Patient on NIV/CPAP
 Yes  No 4.2 Practice address:
information, I may be liable to prosecution or civil proceeding
8. Equipment*
9. Consumables*
5
Cystic
fibrosis
16
Chronic neonatal lung disease
information provided. I also confirm that the patient has read
3.3 2Paediatric
Yes a static
 No
For more than
hours/day Order
it is advisable toselect
concentrator
(select one for each equipment type)
6
Bronchiectasis (not cystic fibrosis)
17
Paediatric cardiac disease
Name:
Type
Quantity
Nasal Canulae 18
Mask
% andheadache
Type
4.3 Postcode*
4.4 Telephone no.
7
Pulmonary malignancy
Cluster
8.1 Static 8
Concentrator
Signature:
Palliative care Service (Hospital or Clinical Service)
19
Other primary
respiratory
disorder
5. Assessment
6. Ward
Details
(if applicable)
Section 5 - Assessment service (hospital or clinical service)
Please complete the details of the Assessment Service that will be used for
follow up purposes.
Day
Back up static cylinder(s) will be supplied as appropriate
Non-pulmonary
palliative care
5.1
Hospital
or Clinic Name:
8.2 Static 9
Cylinder(s)
A single cylinder
for approximately
8hrs at 4l/min
10 will lastChest
wall disease
5.2 Address
10. Delivery
Details*
11
Neuromuscular
disease
Days)

10.2 Next (Calendar) Day
5.3 Postcode:
7. Order*12.1 Name:
Other
6.1 Name:
Not known
6.2 Tel no.:
21

nal Patient Information
Litres / Min
20
10.3 Urgent (4 Hours)

6.3 Discharge date:
5.4 Tel no:
12. Clinical Contact (if applicable)
8. Equipment*
For more than 2 hours/day it is advisable to select a static concentrator
Tel no. Type
Hours12.2
/ Day
12.3 Mobile no.
Quantity
8.1 Static Concentrator
13. Declaration*
Back up static cylinder(s) will be supplied as appropriate
tion given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false
Static Cylinder(s)
e to prosecution or civil proceedings. I confirm that I am the8.2
registered
healthcare professional responsible for the
A single cylinder will last for approximately 8hrs at 4l/min
o confirm that the patient has read and signed the Home Oxygen Consent Form.
Profession:
10.1 Standard (3 Business Days)
Fax back no. or NHS email address for confirmation / correct
CODE
/
1
Condition
/
Chronic obstructive pulmonary disease (COPD)
2
Pulmonary vascular disease
9. 3Consumables*
Severe chronic asthma
(select one for each equipment type)
4
Nasal Canulae
5
Interstitial lung disease
Mask % and Type
Cystic fibrosis
6
Bronchiectasis (not cystic fibrosis)
7
Pulmonary malignancy
8
Palliative care
guide to
the Home Oxygen Order
Form
- part A
10.ADelivery
Details*

10.2 Next (Calendar) Day

9
10.3 Urgent (4 Hours)
Non-pulmonary palliative care

5
1.5 DoB*
2.2 Tel no.
 Male
1.6 Gender
 Female
1.8 Postcode*
3. Clinical Details
2.3 Mobile no.
4. Patient’s Registered GP Information
Section3.26Patient
- Ward
details
(if applicable)
on NIV/CPAP
 Yes  No 4.2 Practice address:
If the patient
is in hospital
3.3 Paediatric Order
 Yes  Noand due for discharge, section 6 should be
4.3to
Postcode*
4.4 Telephone no.
completed. This will enable
us
liaise
Home
Oxygen
Order Form (HOOF)
Part A (Before
Oxygen
Assessment
– Non-Specialist
Order) Details (if applicable)
Assessment
Service
(Hospital
or Clinical
Service) or Temporary
6. Ward
with the5.hospital
to
ensure
a
smooth
and
All fields
marked with a ‘*’ are mandatory and the HOOF will be rejected
not completed
5.1 Hospital or Clinic
Name:
6.1if Name:
1. Patient
Details
consistent
process with minimal
delays
or
5.2 Address
6.2 Tel no.:
1.1 NHS Number*
1.7 Permanent address*
1.9 Tel no.
disruptions.
6.3 Discharge date:
/
/
3.1 Clinical Code(s)
4.1 Main Practice name:*
1.2 Title
5.3 Postcode:
1.3 Surname*
1.10 Mobile no.
5.4 Tel no:
2. Carer Details
8. Equipment*
Home Oxygen Order Form (HOOF)
7. Order*
(if applicable)
9. Consumables*
1.4 First name*
2.1 Name (select one for each equipment type)
For more than 2 hours/day it is advisable to select a static concentrator
Sections
7, 8 and
- Ordering
Part
A9(Before
Oxygen
Assessment – Non-Specialist or Temporary
Order)Nasal Canulae
Litres / Min
Hours / Day
Type
Quantity2.2 Tel no.
Mask % and Type
1.5 DoB*
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
Section
7 relates
to the oxygen
the patient should use.2.3The
amount of oxygen
8.1 Static Concentrator
1.6 Gender
Mobile no.
 Male  Female 1.8 Postcode*1. Patient Details
Static Cylinder(s)
being
needs to 1.7
be8.2Permanent
stated
in
litres per
minute,
together
with the
3.ordered
Clinical Details
4. Patient’s
Registered
GP Information
1.1 NHS Number*
address*
1.9 Tel no.
3.1 Clinical
4.1 Main Practice
name:*
number
of hours of therapy
required
per
day.
1.2
Title Code(s)
1.10
Mobile
no.
10. Delivery Details*
Back up static cylinder(s) will be supplied as appropriate
A single cylinder will last for approximately 8hrs at 4l/min
3.2
on NIV/CPAP
 Business
Yes Days)
No
1.3 Patient
Surname*
10.1 Standard (3
4.2 Practice address:

10.2 Next (Calendar) Day

Urgent
(4 Hours)
2. 10.3
Carer
Details
(if

applicable)
3.3 First
Paediatric
Order
 Yes  NoPatient Information
1.4
name*
2.1 Name
11.the
Additional
12.be
Clinical
Contact (if
applicable)
In
section
8,
mode by which the oxygen is to
delivered
should
be
4.3 Postcode*
12.1 Name:4.4 Telephone no.
1.5 DoB*
2.2 Tel no.
selected.
When
a static
concentrator
is chosen,6.backup
static
cylinders will
5.
Assessment
Service
(Hospital
or
Clinical
Service)
Ward
Details
(if
applicable)
12.2 Tel no.
12.3 Mobile no.
1.6 Gender
2.3 Mobile no.
 Male  Female 1.8 Postcode*
automatically
5.1 Hospital or Clinic Name: be supplied.
6.1 Name:
13. Declaration*
3. Clinical Details
4. Patient’s
Registered GP Information
5.2 Address I declare that the information given on this form for NHS treatment is correct
6.2and
Tel complete.
no.:
I understand that if I knowingly provide false
3.1 Clinical Code(s)
4.1 Main Practice name:*
information, I may be liable to prosecution or civil proceedings. I confirm that I am the registered healthcare professional responsible for the
6.3 Dischargemask
date:
/
/be made.
Practice
address:
For
section
9,provided.
a choice
of4.2that
either
nasal
cannula
3.2 Patient
oninformation
NIV/CPAP
Yes I also
 No
confirm
the patient
has read and
signed the Homeor
Oxygen Consent should
Form.
5.3 Postcode:
3.3
PaediatricName:
Order
 Yes
7.Signature:
Order*
5.4 Tel no:
 No
Home Oxygen Order Form (H
Profession:
8. Equipment*
4.3 Postcode*
Part A (Before Oxygen Assessment – Non-Special
9. Consumables*
Referred
assessment:
Yes
 No
Allfor
fields
marked
with
a ‘*’
are mandatory
and the HOOF will
(select one for each
equipment
type)
4.4 Telephone no.
Date:
For more than 2 hours/day it is advisable to select a static concentrator
5./ Assessment
(Hospital
or Clinical
Service)
6. WardNasal
Details
(if
no./ Service
or
NHS email
address for confirmation
/ corrections:
Litres
Min Fax back
Hours
Day
Type
Quantity
Canulae
5.1 Hospital or Clinic Name:
6.1 Name:
1.1 NHS Number*
14. Clinical
Code
8.1 Static Concentrator
5.2 Address CODE
1. Patient Details
1.7 Permanent address*
Back up static cylinder(s) will be supplied as appropriate
CODE
Condition
6.2
Tel
no.:
1.2
Title
12
Neurodisability
6.3 Discharge
date:
/
/
1.3 Surname*
2
Pulmonary vascular disease
13
Obstructive sleep apnoea syndrome
10. Delivery Details*
5.3 Postcode:
5.4 Tel no:
1.4 First name*
Severe
chronic asthma
14
Chronic
heart failure
10.1 Standard3 (3 Business
Days)

10.2 Next (Calendar) Day

10.3 Urgent
(4 Hours)

8. Equipment*
9. Consumables*
Interstitial lung disease
15 1.5 DoB*
Paediatric interstitial
lung disease
7.4Order*
1
Condition
applicable)
Mask % and Type
8.2 Static Cylinder(s)
Chronic obstructive
pulmonary
(COPD)
A single
cylinder willdisease
last for approximately
8hrs at 4l/min
For more
than 2 hours/day it is advisable to select a static
(select
oneapplicable)
for each equipment type)
11. Additional Patient
Information
12. concentrator
Clinical Contact
(if
5
Cystic fibrosis
16 1.6 Gender
Chronic neonatal 
lung
disease
Male
 Female 1.8 Postcode*
Litres / Min
HoursDelivery
/ Day
Type details
Quantity
Nasal Canulae
Mask % and Type
12.1 Name:
Section
6 10 -Bronchiectasis
(not cystic
fibrosis)
17
Paediatric
cardiac disease
3. Clinical
Details
4. Patient’s Re
8.1 Static Concentrator
12.2 Tel no.
12.3 Mobile no.
7
Pulmonary malignancy
18
Cluster headache
Please indicate
the delivery timescale
required.
3.1 Clinical Code(s)
4.1 Main Practice name:*
Back up static cylinder(s) will be supplied as appropriate
Palliative care 8.2 Static Cylinder(s)
Other primary respiratory disorder
13. Declaration* 19
A single cylinder will last for approximately 8hrs at 4l/min
3.2 Patient on NIV/CPAP
 Yes  No 4.2 Practice address:
Non-pulmonary
20 I understand
Other that if I knowingly provide false
I declare that9the information
given on palliative
this form care
for NHS treatment is correct and complete.
10. Delivery Details*
information, I10
may be liable
prosecution
healthcare
professional 
responsible
Order
Yes for
Nothe
Chesttowall
disease or civil proceedings. I confirm that I am the registered
21 3.3 Paediatric
Not known
information
provided.
I alsoDays)
confirm that
hasNext
read(Calendar)
and signedDay
the Home
10.1 Standard
the patient10.2
Oxygen Consent Form.
10.3 Urgent (4 Hours)

11(3 Business
Neuromuscular disease
4.3 Postcode*
Name:
Profession:
8
11. Additional Patient Information
12. Clinical
Contact (if Service
applicable)
5. Assessment
(Hospital or Clinical Service)
Signature:
Date:
Referred for assessment:
Yes
 No(4
Be
aware that there are cost implications
when
requesting
an 
urgent
12.1 Name:
5.1 Hospital or Clinic Name:
Fax back no. or NHS email address for confirmation / corrections:
12.2 Tel no.
12.3
Mobile
no.
hours)
delivery.
5.2 Address
6.1
6.2
14. Clinical Code
13. Declaration*
6.3
Condition
Condition
ICODE
declare that
the information given on this form for NHS treatment is correctCODE
and complete.
I understand that if I knowingly provide false
5.3 Postcode:
information,
I mayobstructive
be liable topulmonary
prosecution
or civil(COPD)
proceedings. I confirm that
registered
healthcare professional responsible for5.4
theTel no:
1
Chronic
disease
12I am theNeurodisability
information provided. I also confirm that the patient has read and signed the Home Oxygen Consent Form.
8. Equipment*
2
Pulmonary vascular disease
13
Obstructive sleep apnoea
syndrome
7. Order*
For more than 2 hours/day it is advisable to select a static co
Name: Severe chronic asthma
Profession:
3
14
Chronic heart failure
Litres
/
Min
Hours
/
Day
Type
4
Interstitial lung disease
Paediatric interstitial
lung disease
Signature:
Date:15
Referred
for assessment:
 Yes  No
8.1 Static Concentrator
5
Cystic fibrosis
16
Chronic neonatal lung disease
Back up static cylinder(s) will be supplied as appropriate
Fax back no. or NHS email address for confirmation / corrections:
6
Bronchiectasis (not cystic fibrosis)
17
Paediatric cardiac disease
8.2 Static Cylinder(s)
14. Clinical Code
A single cylinder will last for approximately 8hrs at 4l/min
7
Pulmonary malignancy
18
Cluster headache
CODE
Condition
CODE
Condition
10. Delivery Details*
8
Palliative care
19
Other primary respiratory disorder
1
Chronic obstructive pulmonary disease (COPD)
12
Neurodisability

10.2 Next (Calendar) Day

9
Non-pulmonary palliative care
20
Other 10.1 Standard (3 Business Days)
2
Pulmonary vascular disease
13
Obstructive sleep apnoea syndrome
10
Chest wall disease
21
Not known
11. Additional Patient Information
12. C
3
Severe chronic asthma
14
Chronic heart failure
11
Neuromuscular disease
12.1 Name:
4
Interstitial lung disease
15
Paediatric interstitial lung disease
Please bear in mind the “next calendar day” installation option is only
contractually allowable for hospital discharges or following formal blood
gas oxygen assessment (where HOOF Part B should be used).
Section 11 - Additional patient information
This section should be used to advise
us of any special information relating
5 the
Cystic
fibrosis
16
Chronic neonatal lung disease
to
patient’s
oxygen supply and on12.2 Tel no.
6
Bronchiectasis (not cystic fibrosis)
17
Paediatric cardiac disease
13. Declaration*
going
supply
requirements.
This
could
7
Pulmonary malignancy
18
Cluster headache
I declare that the information given on this form for NHS treatment is correct and complete
information,
I may
be liable to prosecution
or civil proceedings. I confirm that I am the regi
8
Palliative
careexample, physical disabilities,
19
Other
primary
respiratory
disorder
include,
for
language
difficulties,
non-English
information provided. I also confirm that the patient has read and signed the Home Oxygen
9
Non-pulmonary palliative care
20
Other
speaker.
Name:
Profession:
10
Chest wall disease
21
Not known
11
Neuromuscular disease
Signature:
Date:
Fax back no. or NHS email address for confirmation / corrections:
14. Clinical Code
6
CODE
A guide to the Home Oxygen Order Form - part
A
1
Condition
CODE
Cond
Chronic obstructive pulmonary disease (COPD)
12
Neuro
no:
1.5 DoB*
8. Equipment*
n 2 hours/day it is advisable to select a static concentrator
 Male
1.6 Gender
2.2 Tel no.
9. Consumables*
(select one for each equipment type)
1.8 Postcode*
 Female
Quantity
3. Clinical
DetailsNasal Canulae
2.3 Mobile no.
Mask % and Type
4. Patient’s Registered GP Information
4.1 Main Practice
name:*
Section 12 - Clinical contact
(if applicable)
address:
3.2 Patient on NIV/CPAP
Yes clinical
 No 4.2 Practice
The
details of the
contact
for the patient need to be incorporated here.
Paediatric
Order
 Yes  No
10. Delivery
Details*
It3.3is
possible
that
this may
be
the
same
person4.4signing
the HOOF Part A and,
4.3 Postcode*
Telephone no.
10.2 Next (Calendar) Day

10.3 Urgent (4 Hours)

in
this
case,
those
details must be
5.
Assessment
Service
(Hospital
or
Clinical
Service)
6.
Ward
Details
(if applicable)
mation
12. Clinical Contact (if applicable)
5.1
6.1 Name:
repeated
here.
12.1Hospital
Name: or Clinic Name:
oncentrator
3.1appropriate
Clinical Code(s)
cylinder(s) will be supplied as
ylinder(s)
er will last for approximately 8hrs at 4l/min
5.2
12.2Address
Tel no.
6.2 Tel no.:
12.3 Mobile no.
13. Declaration*
6.3 Discharge date:
/
or NHS treatment is correct
and complete. I understand that if I 5.4
knowingly
5.3 Postcode:
Tel no: provide false
proceedings. I confirm that I am the registered healthcare professional responsible for the
8. Equipment*
nt has read and signed the Home7.
Oxygen
Consent Form.
Order*
n / corrections:
COPD)
/
9. Consumables*
For more than 2 hours/day it is advisable to select a static concentrator
(select one for each equipment type)
Section
13 - Declaration
Profession:
Litres / Min
Hours / Day
Type
Quantity
Nasal Canulae
Type
This
must
be
fully
completed
before
the
HOOF
PartMaskA%isandsent
to us.
Date: declarationReferred
for
assessment:

Yes

No
8.1 Static Concentrator
We would strongly8.2advise
that
‘Referred
for
assessment’
boxes
are
completed.
Static Cylinder(s)
Back up static cylinder(s) will be supplied as appropriate
14. Clinical Code
A single cylinder will last for approximately 8hrs at 4l/min
10. Delivery Details*
It10.1is12Standard
very
importantthat 10.2
not
only is the declaration
signed, but also a
Neurodisability
(3 Business Days)
Next (Calendar) Day
10.3 Urgent (4 Hours)
Obstructive
sleep
apnoea
syndrome
fax13number/NHS
email
address
is
provided
so
that
we
able to send
11. Additional Patient Information
12. Clinical Contact are
(if applicable)
14
Chronic heart failure
12.1 Name:
confirmation/corrections
back.
15
Paediatric interstitial lung disease
CODE
Condition
16
Chronic neonatal lung disease
12.2 Tel no.
12.3 Mobile no.
13. Declaration*
17
Paediatric cardiac disease
I declare
the information
given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false
18 that Cluster
headache
information, I may be liable to prosecution or civil proceedings. I confirm that I am the registered healthcare professional responsible for the
19
Other primary respiratory disorder
information provided. I also confirm that the patient has read and signed the Home Oxygen Consent Form.
20
Other
Name:
Profession:
21
Not known
Signature:
Date:
Referred for assessment:
 Yes
 No
Fax back no. or NHS email address for confirmation / corrections:
14. Clinical Code
CODE
Condition
CODE
Condition
1
Chronic obstructive pulmonary disease (COPD)
12
Neurodisability
The HOCF
2
Pulmonary vascular disease
13
Obstructive sleep apnoea syndrome
3
Severe chronic asthma
14
Chronic heart failure
4
Interstitial lung disease
15
Paediatric interstitial lung disease
5
Cystic fibrosis
16
Chronic neonatal lung disease
6
Bronchiectasis (not cystic fibrosis)
17
Paediatric cardiac disease
You
will
need
to ask the patient to complete
a Home
Oxygen
Consent Form
8
Palliative
care
19
Other primary
respiratory
disorder
9
Non-pulmonary
palliative
Other
(HOCF)
in order
tocareallow the sharing 20of the
patient’s details with the supplier.
10
Chest wall disease
21
Not known
The
HOCF
does
not need to be sent with the HOOF to the supplier, because
11
Neuromuscular
disease
your signature in the HOOF declaration box confirms that you have obtained
consent to share the patients’ data with us. The
original HOCF should be kept for your records and
a copy provided to the patient.
7
Pulmonary malignancy
18
Cluster headache
Home Oxygen Order Form (HOOF)
Part A (Before Oxygen Assessment – Non-Specialist or Temporary Order)
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
1. Patient Details
1.1 NHS Number*
1.7 Permanent address*
1.9 Tel no.
1.2 Title
1.10 Mobile no.
2. Carer Details
1.3 Surname*
1.4 First name*
It is worth emphasising with patients the part
of the Home Oxygen Consent Form that states
that the patient agrees to allow the supplier
reasonable access to their property to install,
refill, service and also remove equipment as
appropriate. This will help patients to understand
that this may be a temporary order and that
following assessment it may be proved that the
equipment is not clinically necessary and so will
be removed.
(if applicable)
2.1 Name
1.5 DoB*
2.2 Tel no.
 Male
1.6 Gender
 Female
1.8 Postcode*
2.3 Mobile no.
3. Clinical Details
4. Patient’s Registered GP Information
3.1 Clinical Code(s)
4.1 Main Practice name:*
3.2 Patient on NIV/CPAP
 Yes
 No
3.3 Paediatric Order
 Yes
 No
4.2 Practice address:
4.3 Postcode*
4.4 Telephone no.
5. Assessment Service (Hospital or Clinical Service)
6. Ward Details (if applicable)
5.1 Hospital or Clinic Name:
6.1 Name:
5.2 Address
6.2 Tel no.:
6.3 Discharge date:
5.3 Postcode:
7. Order*
Litres / Min
/
/
5.4 Tel no:
Hours / Day
8. Equipment*
9. Consumables*
For more than 2 hours/day it is advisable to select a static concentrator
Type
(select one for each equipment type)
Quantity
Nasal Canulae
Mask % and Type
8.1 Static Concentrator
Back up static cylinder(s) will be supplied as appropriate
8.2 Static Cylinder(s)
A single cylinder will last for approximately 8hrs at 4l/min
10. Delivery Details*
10.1 Standard (3 Business Days)


10.2 Next (Calendar) Day
11. Additional Patient Information
10.3 Urgent (4 Hours)

12. Clinical Contact (if applicable)
12.1 Name:
12.2 Tel no.
12.3 Mobile no.
13. Declaration*
I declare that the information given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false
information, I may be liable to prosecution or civil proceedings. I confirm that I am the registered healthcare professional responsible for the
information provided. I also confirm that the patient has read and signed the Home Oxygen Consent Form.
Name:
Profession:
Signature:
Date:
Referred for assessment:
 Yes
 No
Fax back no. or NHS email address for confirmation / corrections:
14. Clinical Code
CODE
Condition
CODE
Condition
1
Chronic obstructive pulmonary disease (COPD)
12
Neurodisability
2
Pulmonary vascular disease
13
Obstructive sleep apnoea syndrome
3
Severe chronic asthma
14
Chronic heart failure
4
Interstitial lung disease
15
Paediatric interstitial lung disease
5
Cystic fibrosis
16
Chronic neonatal lung disease
6
Bronchiectasis (not cystic fibrosis)
17
Paediatric cardiac disease
7
Pulmonary malignancy
18
Cluster headache
8
Palliative care
19
Other primary respiratory disorder
9
Non-pulmonary palliative care
20
Other
10
Chest wall disease
21
Not known
11
Neuromuscular disease
A guide to the Home Oxygen Order Form - part A
7
Progressing your order
Once the HOOF Part A is fully completed, please fax it to:
0800 214709
Please note: You will not need to write repeat order forms each time your
patient needs a replenishment of oxygen cylinders. We are committed
to delivering your patient’s oxygen requirements until we are notified
otherwise.
Delivery timescales
There are three delivery options, as per Section 10 of the HOOF Part A:
•
•
•
Standard (3 business days)
Next (calendar) day
Urgent (4 hours)
Please bear in mind the “next calendar day” installation option is only
contractually allowable for hospital discharges or following formal blood gas
oxygen assessment (where HOOF Part B should be used).
Urgent deliveries will be supplied within 4 hours. Next day and standard
supply timescales are as shown as follows:
Please note that there is an additional charge for an urgent delivery.
Day order
received
Next day installation
Standard installation
Received
Before 5.00pm After 5.00pm
Before 5.00pm After 5.00pm
Mon
Tue
Wed
Thu
Fri
Tue
Wed
Thu
Fri
Mon
Wed
Thu
Fri
Mon
Tue
Thu
Fri
Sat
Tue
Wed
Fri
Sat
Sun
Wed
Thu
Sat
Sun
Mon
Thu
Thu
Sun
Mon
Tue
Thu
Thu
8
A guide to the Home Oxygen Order Form - part A
Equipment available
Static concentrators
Static concentrators are the most convenient source of home supplied oxygen
available today.
The static concentrator is electrically operated.
Note: The static concentrator does not store any volume of oxygen and it
does not affect the air quality in the user’s environment.
Flow rates from 0.1 lpm to 15 lpm can be accommodated (some high flow rates
will require multiple concentrators).
Example concentrator - AirSep Newlife Elite
Weight
Height
Width
Depth
24.5kg (54lb)
68cm (26.7ins)
38cm (14.9ins)
28cm (11ins)
The actual model supplied may vary from
the example shown.
A guide to the Home Oxygen Order Form - part A
9
Static cylinders (B10)
Static cylinders may be prescribed
as the mode of supply for low-usage
patients, and will be provided to all
patients using a concentrator for use as
backup in the event of power failure, or
machine malfunction.
Should your patient suffer from cluster
headaches, static cylinders together
with a non-rebreathe mask, is normally
the most suitable order.
Weight full
15kg-18kg (33lb-39lb)
Height
71cm (28ins)
Diameter
18.2cm (7.1ins)
Capacity
2122 litres
10
A guide to the Home Oxygen Order Form - part A
The Air Products Mode of Supply
Tool with e-HOOF facility:
Together with a small group of clinicians familiar with ordering home
oxygen, Air Products have developed an online tool to help clinicians make
good decisions regarding home oxygen equipment. The tool recommends
equipment based on:
•
•
•
Clinical suitability
Lifestyle suitability
NHS value for money
The tool also generates an electronic HOOF Part A with built in validation so
that all the mandatory fields are completed in full and the order can then be
processed without rejection. The HOOF can be exported and saved for your
records, and if saved as an excel table, it can be later modified if necessary and
re-sent.
The tool aims to:
•
•
•
Ensure equipment meets the needs of patients
Control NHS costs
Reduce frustration for clinicians re HOOF process
Please refer to the clinician’s web pages of our website for more information
on how to register for use of this tool and gain access.
www.airproducts.co.uk/homecare
A guide to the Home Oxygen Order Form - part A
11
tell me more
For more information
please contact us at:
Air Products Healthcare
2 Millennium Gate
Westmere Drive
Crewe
Cheshire, CW1 6AP
Telephone: 01270 218050
Email: [email protected]
or visit www.airproducts.co.uk/homecare
© Air Products and Chemicals, Inc. 2012
365-12-035-UK