Oxygen Therapy Request for Prior Authorization and Prescription - medicaid alabama 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Information. Fill in the Patient Name, Medicaid Number, Date of Birth, and Diagnosis accurately to ensure proper identification.
3. In the Prescription Information section, indicate whether this is an Initial or Renewal request. Provide the Date last seen by a physician, Date oxygen was prescribed, Liters per minute required, and Hours per day the oxygen will be used.
4. Specify the Method of delivery (e.g., nasal cannula or mask) and if portable oxygen is prescribed, state its purpose. Estimate how long (in months) the oxygen will be needed.
5. Describe the type, duration, and frequency of daily activities outside the home to provide context for medical necessity.
6. Select the Equipment Prescribed from options like Compressed Gas or Oxygen Concentrator for both stationary and portable systems.
7. Input Laboratory Results including ABG (P02) result and Oxygen Saturation levels. Ensure to attach a copy of relevant reports as required.
8. Finally, have your physician certify that oxygen is medically necessary by signing and dating the form. Remember that stamped signatures are not acceptable.

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