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DVA - D804 - Application for Home Medical Oxygen Therapy - dva gov

DVA - D804 - Application for Home Medical Oxygen Therapy - dva gov 2026

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The document is an application form for Home Medical Oxygen Therapy and Respiratory Home Therapy Appliances, specifically for veterans and their dependants. It includes sections for personal information, delivery details, medical conditions, and prescriber information. The form emphasizes the protection of personal data under the Privacy Act 1988 and provides contact information for assistance. It outlines eligibility criteria, required medical endorsements, and details regarding oxygen therapy supplies.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the 'Patient/Entitled Person - Delivery Details' section. Enter your surname, given names, address, phone number, postcode, date of birth, and DVA file number. Select your card type (Gold or White).
If applicable, provide the delivery address if different from the above. Include the postcode and any prior approval number issued by DVA.
Complete the 'Specialist Physician Details' section. Input the prescriber’s name, specialty, address, provider number, phone number, and signature.
In the 'Requested Supply System' section, select your medical conditions and specify any additional requirements for oxygen therapy.
Fill out the 'Indications for Oxygen Therapy' with relevant details such as flow rates and oxygen saturation levels during various activities.
Review all sections for accuracy before saving or submitting your application through our platform.

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Versions	Form popularity	Fillable & printable
2022	4.5 Satisfied (21 Votes)
2021	4.6 Satisfied (39 Votes)
2012	4 Satisfied (28 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get approved for home oxygen?

--To purchase an oxygen concentrator, you do need a prescription from your primary doctor, stating your oxygenlevel. The US Food Drug Administration (FDA) makes the rules about prescription sales, and at this time, oxygen concentrators are one of the medical devices for which the FDA requires a prescription.

Does the VA cover portable oxygen concentrators?

Veterans Affairs (VA) benefits For Veterans, VA health care may provide full coverage for a portable oxygen concentrator if it is deemed medically necessary. If you are a Veteran receiving health care through the VA, check with your provider to see if you qualify.

Will the VA pay for a portable oxygen concentrator?

Home oxygen therapy can be useful for people who do not have enough oxygen in their blood. It can help with conditions such as: chronic obstructive pulmonary disease (COPD) pulmonary fibrosis.

Does medical cover portable oxygen concentrators?

Oversaturating the blood stream with supplemental oxygen can thus depress respiratory drive in these patients causing dyspnea and/or respiratory failure. For these reasons, supplemental oxygen therapy requires a prescription from a physician.

Who is eligible for oxygen at home?

Rotech has provided home oxygen and durable/home medical equipment services under contract to the Department of Veterans Affairs for more than 20 years. We take pride in providing our exceptional industry-leading service and high-quality equipment to our nations Veterans.

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