Transcription of Home Oxygen Program Application Form
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Home Oxygen Program Application Form
home Oxygen ProgramApplication FormThe PEI home Oxygen Program provides approved patients diagnosed with Chronic Obstructive Pulmonary Disease(COPD) with financial assistance of up to 50% of their approved home Oxygen expenses to a maximum of $200 expenses are limited to: Oxygen concentrator rental, purchase, or maintenance Nasal cannula - maximum one per month Oxygen tubing - maximum one per month Humidifier bottle - maximum one per month Size E or larger Oxygen cylinder, cylinder base, flow meter regulator, and refills - to be used for power orequipment failure Liquid Oxygen and delivery equipment rental, purchase, or maintenance Portable Oxygen cylinders with an Oxygen conserving device - maximum 10 cylinders per monthCosts associated with damage to equipment or additional supplies are the responsibility of the most patients.
HOME OXYGEN PROGRAM APPLICATION FORM - PAGE 2 PART II - To be completed by a Physician This is to confirm that the above named applicant meets …
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