Attachment K Updated.xlsx
XLSX spreadsheet 13 KB Posted
- Attached to
- Q999 - VISN 12 Home Oxygen Delivery Services
- Solicitation number
- Not on record
About this file
The file is a VA Forms Matrix for VISN 12 Home Oxygen Delivery Services, detailing specific documentation requirements for respiratory equipment service delivery. The matrix outlines multiple VA forms that must be completed and maintained electronically for various respiratory equipment scenarios, including oxygen and ventilator set-ups, exchanges, maintenance visits, and patient interactions.
Key forms include VA 1619 (Respiratory Equipment Delivery & Education), VA 1623 (Smoking Risk Acknowledgment), VA 1620 (Veteran Rights & Responsibilities), VA 1618 (Ventilator Function Check), and VA 1621 (Patient Decision Against Medical Advice). The document specifies requirements for different types of respiratory equipment set-ups, such as oxygen systems, ventilators, suction devices, and 50 PSI compressors, with notes indicating that while some forms do not require direct submission to the VA, vendors must obtain and maintain them in electronic health records.
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Other files
| File | Type | Posted |
|---|---|---|
| S06 - 36C25225R0072 0001.docx | DOCX document |
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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 .