LINCARE - Fax: 866-846-9375

QUICK REFERRAL FOR RESPIRATORY AND OTHER SERVICES

Patient Information

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Are Patient Demographics Attached?  Yes   or     No
Name:*			DX:
Address:*			Diagnosis Codes:
			Length of Need:
City:*
State:*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY     Zip:*		Primary Insurance:
Phone:*			Policy Number:
D.O.B.:*			Secondary Insurance:
Order Date:*			Policy Number:
Physician Name:*			Physician Phone:*
			NPI #:

LINCARE - Fax: 866-846-9375

QUICK REFERRAL FOR RESPIRATORY AND OTHER SERVICES

Patient Information

Are Patient Demographics Attached?  Yes   or     No
Name:		DX:
Address:		Diagnosis Codes:
		Length of Need:
City:
State:    Zip:		Primary Insurance:
Phone:		Policy Number:
D.O.B.: //		Secondary Insurance:
Order Date: 4/25/2024		Policy Number:
Physician Name:		Physician Phone:
		NPI #:

Oxygen	LPM     Hrs/Day     SpO2/PaO2    Date of Test: Date Last Seen:
Oximetry	Overnight      Spot Check      Titration      Conserver  On Room Air      On CPAP at cmH2O  On O2 at LPM      On Bilevel at IPAP cmH2O      EPAP cmH2O  Titration to be performed to achieve O2 saturation of %
Care Check (COPD Education and Assessment)
TEAM
HeartSteps (CHF Education and Assessment)
CPAP	cmH2O     Interface     Humidification    Cool   or     Heated
Bilevel Therapy	IPAP    cmH2O       EPAP    cmH2O       RR         Humidification    Cool   or     Heated
Nebulizer	Stationary   or     Portable
PATIENT SELF TESTING PROVIDED BY mdINR
mdINR (PT/INR)
MEDICATION PROVIDED BY RELIANT PHARMACY (PLEASE ATTACH PAD RX)

Ipratropium 0.5mg/Albuterol 2.5mg Unit Dose Solution 3ml	Frequency	Quantity	Refills
Albuterol Sulfate Unit Dose Solution 0.083% 3ml	Frequency	Quantity	Refills
Ipratropium Bromide Unit Dose Solution 0.02% 2.5ml	Frequency	Quantity	Refills
Budesonide INH Suspension 0.25 mg 2ml	Frequency	Quantity	Refills
Budesonide INH Suspension 0.5 mg 2ml	Frequency	Quantity	Refills
PERFOROMIST	Frequency	Quantity	Refills
BROVANA	Frequency	Quantity	Refills
Special Instructions: