Attachment K Updated.xlsx
XLSX spreadsheet 13 KB Posted
- Attached to
- Q999 - VISN 12 Home Oxygen Delivery Services
- Solicitation number
- 36C25225R0072
About this file
This document is a Forms Matrix for VISN 12 Home Oxygen Delivery Services, detailing the specific VA forms required for various respiratory equipment services and patient interactions. The matrix covers multiple types of equipment set-ups including oxygen (O2), ventilator, and miscellaneous respiratory equipment, with specific form requirements for each service type such as new equipment set-ups, maintenance, exchanges, and patient education.
The matrix identifies several key VA forms that must be completed and maintained electronically, including VA Form 1619 (Respiratory Equipment Delivery & Education), VA Form 1623 (Smoking Risk Acknowledgment), VA Form 1620 (Veteran Rights & Responsibilities), VA Form 1618 (Ventilator Function Check), and VA Form 1621 (Patient Decision Against Medical Advice). The document is associated with VA Solicitation Number 36C25225R0072 for Home Oxygen Delivery Services, specifically for Veterans Integrated Service Network 12 (VISN 12), and provides detailed guidance on documentation requirements for respiratory equipment service providers.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| S06 - 36C25225R0072 0001.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Sheet1
| VISN 12 REQUIRED FORMS MATRIX | ||||
| VA Forms | Transition | Oxygen | Ventilator | Misc. |
Respiratory Equipment Set-Ups
| (See Note 1) | Monthly 50 PSI Compressor Visits | |
| New |
O2 Set-Up O2 Maint / Equipment Exchanges / Annual & Semiannual Reeducation POC Set-Up /
| POC Exchanges | Vent | |||||||||
| Set-Up | Vent Exchanges & Monthly RT Vent Visits | |||||||||
| Form # | Form Title | |||||||||
| VA 1619 | PMI - Respiratory Equipment Delivery & Education | VA 1619 | VA 1619 | VA 1619 | VA 1619 | Note 2 | VA 1619 | VA 1619 | ||
| VA 1623 | Smoking Risk Acknowledgment | VA 1623 | ||||||||
| VA 1620 | Veteran Rights & Responsibilities *** | VA 1620 | VA 1620 | VA 1620 | VA 1620 | |||||
| VA 1618 | Ventilator Function Check | VA 1618 | VA 1618 | |||||||
| VA 1621 | Patient Decision Against Medical Advice (AMA) | As Required | ||||||||
| VA 1617 | Priority Patient Concern (PPC) | As Required |
Note 1: Miscellaneous Set-Ups pertain to all other respiratory equipment set-ups other than O2 & Vent Set-Ups, which are listed separtely in this matrix. These set-ups would include, but are not limited to: suction devices, 50 PSI compressors, etc.
Note 2: New vent & O2 patients would also require a VA 1619 form.
*** Vendor is not required to submit these forms to the VA, but is required to obtain and maintain them in their electronic health record system.
File details come from the government source that posted it. Updated .