Adult/Paediatric Oxygen Annual Re-application & Change of
Prescription Request Form
1. CLIENT INFORMATION
Medicare No
Last Name
First Name
Title
Mr
Master
Miss
Mrs
Ms
Date of birth:
Address
Suburb
Postcode
Phone
Mobile
2. OTHER ASSISTANCE
In the past year has the client become eligible or is having assistance from any of the following?
Extended Aged Care at Home (EACH or EACHD) package
Yes
No
Resident of an Aged care facility
Yes
No
Lifetime Care and Support Scheme
Yes
No
Workcover, Compulsory Third part or other third party compensation
Yes
No
Dust Diseases Board
Yes
No
Veterans Affairs assistance
Yes
No
Younger People in Residential Aged Care Programs (YPIRAC)
Yes
No
Other:
Yes
No
Does the client have private health insurance with extras
Yes
No
Yes
No
Yes
No
3. CLINICAL ASSESSMENT
Consumer is aware that they will not be eligible for funding if they to smoke.
The client’s condition continues to be stable and requires Long Term Oxygen Therapy at
home.
Have there been any significant interruptions to the consumer’s need for oxygen therapy
in the past 12 months. If Yes please specify (e.g. hospital admission):
The consumer’s prescription is:
24 hours/day (continuous)
≥16 hours/day
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
Nocturnal
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Adult/Paediatric Oxygen Annual Re-application & Change of
Prescription Request Form
Please indicate reason for application:
Change of prescription
12 month annual review
N.B. if the client’s prescription has changed (i.e. and additional equipment is required) an application
addressing the relevant criteria for the new equipment will be required.
4. EQUIPMENT DECISION (SPECIFICATIONS)
Concentrator:
l/min
C Cylinder:
l/min
Regulator:
D Cylinder:
l/min
N.B. if the client’s prescription has changed (i.e. and additional
Standard
Conserver
equipment is required) an application addressing the relevant criteria for
the new equipment will be required.
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:
5. PLAN FOR IMPLEMENTATION
Which supplier (company) is providing the oxygen supply to the client?
Delivery address for equipment:
Clients home address
Other, provide details below:
Name:
Address:
Phone:
Fax:
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult/Paediatric Oxygen Annual Re-application & Change of
Prescription Request Form
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.as
p#P35_2008
6. 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:
7. 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. 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:
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult/Paediatric Oxygen Annual Re-application & Change of
Prescription Request Form
EnableNSW contact details
Email:
[email protected]
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).
HealthShare NSW – EnableNSW 2015
Developed in collaboration with LTCSA & ACI – Respiratory Network
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