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St or with exercise (percent): Lowest Oxygen Saturation during sleep (percent): Flow rate (I/min.): Is oxygen therapy required for mobility when leaving the home? F00039 Arterial PO2 (mm Hg): Arterial PO2 (mm Hg): Hours of treatment per day (estimated): Is oxygen therapy required for mobility within the home? Prescribing Physician Signature: or or Yes Yes No No Date: / / Submit with completed Title XIX Home Health Services (Title XIX) DME/Medical Supplies Physician Or.

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