Get Specialized Pulse Oximetry Testing Service

Filling out the Specialized Pulse Oximetry Testing Service form online is a straightforward process. This guide will walk you through each step and section of the form to ensure that you complete it accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the designated area.
2. Begin by entering the patient's name in the designated field, along with the face-to-face (F2F) date if applicable.
3. Provide the patient's street address, city, state, and zip code in the corresponding fields.
4. Fill in the home phone number and alternative contact number under the provided sections.
5. Enter the patient's date of birth, sex, marital status, and social security number as requested.
6. Complete the Durable Medical Equipment (DME) name and its city and state.
7. List the phone number and fax number for the DME provider.
8. Indicate whether the patient has Medicare or Medicaid by checking the appropriate box and providing the necessary numbers.
9. Fill in the insurance name, ID number, and group number, along with the insured person's name and date of birth.
10. Specify the relationship of the insured person to the patient by selecting the corresponding option.
11. Enter any relevant diagnosis (ICD-9) codes for the patient's medical condition.
12. In the test order section, indicate whether the test is a nocturnal study on room air or oxygen, and provide additional details as required.
13. Select the reason for the test based on the options provided and add any additional comments if necessary.
14. Complete the physician’s information, including their name, NPI number, address, phone, and fax.
15. Sign the form digitally by indicating the physician’s signature and the date.
16. Once all fields are filled, review the information for accuracy, then choose to save changes, download, print, or share the completed form as needed.

Complete your Specialized Pulse Oximetry Testing Service form online today!