SoonerCare requires this certificate of medical necessity when a supplier provides home oxygen to a member. The treating physician answers the clinical questions in Section B: the most recent blood gas or oxygen saturation result, test conditions, flow rate and, for borderline results, heart failure edema or pulmonary hypertension. The supplier uses the signed certificate for its prior authorization or claim.
The supplier fills in Section A and the equipment narrative and charges in Section C. Section B may not be completed by the supplier; the physician or a named non-supplier person answers it, and the treating physician signs Section D.
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity - Oxygen
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. The form states that information in Section B may not be completed by the supplier of the items. If someone other than the physician answers the Section B questions, their name, title and employer must be printed on the form, and the treating physician still signs the attestation.
The most recent arterial blood gas PO2 and/or oxygen saturation on or before the certification date, the test date, and whether it was taken at rest, during exercise or during sleep. If more than 4 LPM is ordered, results of a test on 4 LPM are also required.
Section B asks for the estimated length of need in months, from 1 to 12, along with the diagnosis codes. The top of the form marks the certification type as initial, revised or recertification, each with its own date.