Paediatric Long 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: // OR
Date of assessment in room: //
(if client has not been acutely unwell for ≥ 3 months)
The client’s condition is stable and requires Long Term Oxygen Therapy for management in the home / Yes / No
Please complete only one of either A orB
Prescription is ≥ 16 hours (continuous)
Technical and Physician report of prolonged oximetry whilst breathing room air, demonstrating desaturation to ≤ 90%for ≥ 5% of the artefact free recording periodANDmean SpO2 ≤ 93%(copy attached)
PLUS
Technical and Physician report of prolonged oximetry whilst clinically stable and on oxygen, demonstrating improvement in oxygen saturation(copy attached)
PLUS
Objective evidence (i.e. blood gas) that improved oxygenation is not associated with CO2 retention (copy attached)
PLUS
Investigations were performed during period clinical stability (i.e. ≥ 4 weeks out from acute exacerbation)
Prescription is ≥ 6 hours (nocturnal)
Technical and Physician report of sleep study or nocturnal oximetry demonstrating SpO2 demonstrating SpO2 ≤ 85% for ≥ 5% of the night AND mean SpO2≤ 93%(copy attached)
OR
Technical and Physician report of sleep study or nocturnal oximetry demonstrating repetitive desaturations in SpO2 ≤ 85% associated with central apneas and/or hypopneas(copy attached)
PLUS
Technical and Physician report of sleep study or nocturnal oximetry demonstrating improvement in mean nocturnal SpO2 on oxygen therapy with/without PAP therapy (copy attached)
PLUS
Objective evidence (i.e. blood gas) that improved oxygenation is not associated with CO2 retention (copy attached)
PLUS
Investigations were performed during period clinical stability (i.e. ≥ 4 weeks out from acute exacerbation)
4.ELIGIBILITY - PORTABLE OXYGEN
Prescription is for continuous (24 hour) long term oxygen therapy
Justification of the requirement for portable oxygen therapy (copy attached)
5.EQUIPMENT DECISION (SPECIFICATIONS)
Concentrator: l/min
C Cylinder: l/min(Portable oxygen criteria addressed) / Regulator: / Standard / Conserver
D Cylinder: l/min(Justification letter attached)
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/carer 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
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:
-
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:
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:
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:
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.

HealthShare NSW– EnableNSW 2015Page 1 of 4

Developed in collaboration with LTCSA & ACI – Respiratory Network