* 1. Date of Complaint:

Date:
/
/

* 2. Are you a COPD Patient?

* 3. Do you have Alpha-1 Antitrypsin Deficiency?

* 4. Caller's Information:

* 5. Oxygen Supplier Name, Address and Phone Number:

* 6. Type of oxygen equipment used:

* 7. How many months have you continuously used your current equipment?

* 8. Have you reached your 36-month cap?

* 9. Was your prescription written specifically for liquid oxygen?

* 10. Overview of the problem (what you were told and by whom):

* 11. Have you contacted anyone at your oxygen supplier company or Medicare to report the issue?

* 12. What was the outcome of this problem?

* 13. Was it resolved?

* 14. Is it ongoing?

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