http://www.copdfoundation.org/ Oxygen Access Complaint Form Question Title * 1. Date of Complaint: Date: Date Question Title * 2. Are you a COPD Patient? Yes No If No, What is your condition? Question Title * 3. Do you have Alpha-1 Antitrypsin Deficiency? Yes No Question Title * 4. Caller's Information: Caller's Name: Phone Number: Email: Address: Question Title * 5. Oxygen Supplier Name, Address and Phone Number: Question Title * 6. Type of oxygen equipment used: Question Title * 7. How many months have you continuously used your current equipment? Question Title * 8. Have you reached your 36-month cap? Yes No Unsure Question Title * 9. Was your prescription written specifically for liquid oxygen? Yes No What liter flow? Question Title * 10. Overview of the problem (what you were told and by whom): Question Title * 11. Have you contacted anyone at your oxygen supplier company or Medicare to report the issue? Yes No If yes, who and what was the response? Question Title * 12. What was the outcome of this problem? Question Title * 13. Was it resolved? Yes No Comments: Question Title * 14. Is it ongoing? Yes No Comments: Done
