Odm 01909: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Identifying Information section. Enter the individual's name, Medicaid ID number, date of birth, and contact details for both the prescriber and provider.
In the Certification section, mark whether this is an initial request, a renewal, or a revision. Provide diagnosis codes and dates of evaluations as required.
Complete the blood gas study results for at rest, ambulating, and sleeping conditions. Ensure you include PO2 levels and saturation percentages along with their respective dates.
Indicate the estimated length of need by selecting either Group I or Group II criteria based on the patient's condition.
Specify equipment needs in the Specifications section by choosing between stationary or portable systems and detailing flow rates and interfaces.
Finally, have the prescriber complete the Attestation section by signing and dating it to confirm accuracy.

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