Physician Center

Patient Referral Form

If you have a patient who is on oxygen therapy and feels limited by their current set-up, a Portable Oxygen Concentrator may be the solution to their problem. Fill out the form and they will be contacted by one of Open-Aire's Referral Coordinators immediately. Or if you prefer to submit their information via fax you can download our Patient Agreement Form and Patient Referral Form below. Simply fill them out, and fax them back to 866.240.7685 and we will follow up with your patient.

Referring Facility (All fields are required.)

Referring Professional's Name

Primary Contact

Fax Number

Physician Name

Phone Number

NPI Number

Patient Information (All fields are required.)

Name

City

Zip

Sex

Address

State

Phone

Date of Birth

Primary Diagnosis

COPD Chronic Bronchitis Emphysema Asthma

Other:

Primary Insurance

Medicare # PPO/HMO #

Oxygen Order and Laboratory Information (All fields are required.)

Portable Oxygen Therapy System for stationary and portable home oxygen therapy

1. O2 ORDER:

As Needed While Active 24 Hours Daily

2. O2 SETTING Liter Flow / Setting (via Nasal Cannula)

3. Qualifying SAT at rest:

Test Date:

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