Paediatric Short Term Oxygen Therapy Assistive Technology Request Form

1.CLIENT INFORMATION
Last Name
First Name / Medicare No
Title Master Miss Mr / Date of birth:
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: //
Please complete only one of A to B
Prescription is ≥ 16 hours (continuous)
Client is nearing date of discharge from health service and first month has been funded by the discharging service
PLUS
Technical and Physician report of prolonged oximetry demonstrating SpO2 demonstrating SpO2 ≤ 90% for more than a third of the artefact free recording time whilst breathing room air (copy attached)
OR
Technical and Physician report of prolonged oximetry demonstrating SpO2 demonstrating SpO2 ≤ 80% for more than 10% of the artifact free recording time whilst breathing room air (copy attached)
Prescription is ≥ 6 hours (nocturnal)
Client is nearing date of discharge from health service and first month has been funded by the discharging service
PLUS
Technical and Physician report of sleep study ornocturnal oximetry demonstrating repetitive desaturations in SpO2 ≤ 85% whilst breathing room air (copy attached)
OR
Technical and Physician report of sleep study or nocturnal oximetry demonstrating SpO2 ≤ 80% for more than 10% sleep time (copy attached)
4.EQUIPMENT DECISION (SPECIFICATIONS)
Concentrator: l/min
C 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 lives? / Yes / No
Has the consumer been made aware that data regarding compliance with therapy will be collected and reported to the prescriber? / Yes / No
Does the client use any other respiratory equipment?
If Yes, please specify: / Yes / No
5.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
-http://www.deus.nsw.gov.au/energy/Information%20for%20Consumers/Energy%20Rebates.asp#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:
Qualification/role:
Phone:
Email: / Address:
Provider Number:
Fax:
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 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:
Phone:
Email: / Provider Number:
Fax:
Other Contact 2:
Name:
Address:
Qualification/role:
Phone:
Email: / Provider Number:
Fax:
EnableNSW contact details
Email: /
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.

HealthShareNSW – EnableNSW 2015Page 1 of 4

Developed in collaboration with LTCSA & ACI – Respiratory Network