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Referring Oxygen

Thank you for choosing Oxygen One

At Oxygen One we believe that part of providing high-quality care is ensuring insurance coverage of therapy. That is why we strive to obtain all necessary documentation of medical necessity. 


If your patient qualifies for therapy, please fax the following to our office at (262)521-2249:


Five Element Order Prescription including:

  • Patient’s Name
  • Description of the Item
  • Physician Signature
  • Physician’s NPI
  • Date (on or after the face-to-face encounter)

**Click here to download a Five Element Order Form**


Chart Notes

Physician signed clinical notes from the past 30 days supporting medical necessity and discussing symptoms/prognosis (shortness of breath, chronic respiratory indications, hypoxia-related symptoms, etc.) Diagnosis alone is not sufficient. A chart note’s primary purpose is to demonstrate the clinical necessity and show why the patient requires therapy.

A valid note should include:

  • Diagnosis of a severe respiratory disease or other condition that will improve with oxygen therapy such as COPD, cystic fibrosis, CHF

Hypoxia or Pneumonia alone is not a covered diagnosis.

  • Duration of the patient's medical condition
  • Clinical course (worsening or improvement)
  • Prognosis
  • Nature and extent of functional limitations
  • Length of need
  • Other therapeutic interventions and results (e.g. past experiences with related items)
  • Why does the patient require the item?
    • Physical exam findings
    • Signs and symptoms that indicate the need for the item
    • Support that the patient is mobile within the home and that the qualifying testing was performed at rest or during exercise
    • Refill quantity (e.g. Refills: portable monthly x 12 mo./stationary monthly x 12 mo.)
    • Practitioner's signature

Qualifying Testing

  1. SPO2 on room air resting awake
  2. SPO2 on room air with exertion
  3. SPO2 on __lpm with exertion


  • Must be part of the patient's chart (notes or home O2 evaluation)
  • Either #1 or #2 must be at or below 88%
  • #3 must show improvement in SPO2
  • Must be performed either during an inpatient hospital stay, no earlier than 2 days prior to the hospital discharge date and was the last test obtained prior to discharge or performed in the clinic while the patient was in chronic stable state and not during a period of acute illness


Patient Demographics

  • Name
  • DOB
  • Phone number
  • Address
  • Insurance information


For more details on what should be included in your oxygen order, download a copy of our Oxygen Order Checklist and Reference Guide

For further information on Medicare’s coverage guidelines, review their Local Coverage Determination of Wisconsin

After we get the patient setup with their new equipment, our office will fax you a Certificate of Medical Necessity (CMN) for you to complete. A CMN is necessary for Oxygen One to bill the insurance on behalf of the patient.

If you have questions about the referral process at any time, please contact our office for assistance.



Download our Oxygen and Nebulizer Referral Form:



View our Oxygen Equipment Comparison Guides: