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M/ DD/ YYYY) Hours of use: continuous, with exertion, hours of sleep, bleed into CPAP/BiPAP or other Delivery Device: concentrator, portable cylinders, conserving device, liquid Helios portable, or other Date of saturation test: (MM/ DD/ YYYY) Oxygen Saturation or PO2 results: % ****Attach all history & physical, discharge plans, any surgical reports, treatment and medication list*** SECTION C Physician Attestation and Signature/Date I certify that I am the treating physician id.

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