For healthcare professionals · Home oxygen services

Online test request

Complete the request, review it, then print or save a PDF for physician signature and submission by the office’s approved method.

Entry and printing only — this form does not submit online. Information stays in this page and is not saved by the website. Call 951-368-0428 for submission instructions. Fax: 951-368-0429.

Fields marked * are required for the completed request. This form is for professional referrals. Patients may call the office to request care. For a medical emergency, call 911.

1. Referring professional

Identify the person preparing this request. These details do not independently verify identity.

Your full name *Role / title *Organization *Callback phone *Professional emailFax

2. Patient information

Enter the patient’s information as it should appear on the request.

Last name *First name *Date of birth *Sex (as recorded on the original form)Street address *City *State *ZIP code *Phone *Alternate phonePrimary insurancePolicy numberDoes the patient currently have oxygen at home?

3. Clinical information

Provide the referring clinician’s diagnoses and current respiratory medication information.

Primary diagnosisPrimary ICD-10 codeSecondary diagnosisSecondary ICD-10 codeCurrent respiratory medications

4. Requested service

Select at least one service.

Home Physician Evaluation (O2 Certification) Oximetry Study with Exercise

DME organizationDME contact representativeDME phoneDME fax

5. Referring physician

Complete the physician identification fields. Obtain the physician’s signature on the printed request.

Physician name *NPI *California license number *Physician phone *Physician faxPhysician street addressPhysician cityPhysician statePhysician ZIP code

No information is sent when you review or print. Closing or reloading this page may discard your entries. Physician identifiers are entered by the requester and are not verified by this form.

Online test request

Your completed request