This “Authorization to Provide Notice” form is to be used by providers of oxygen or oxygen delivery systems when the provider has received an order from a licensed health care practitioner and is required to notify the fire department or company serving the municipality in which a patient resides of the name and address of the patient and the existence of oxygen or an oxygen delivery system at that residence, pursuant to N.J.S.A. 52:17B-139.7

AUTHORIZATION TO PROVIDE NOTICE

_______ The use of oxygen or an oxygen delivery system in the home poses special safety hazards to the patient, other occupants of the home, neighbors and firefighters in the event of a fire in the home. For this reason, the New Jersey Legislature passed a law which provides a process for notifying local fire departments of the existence of oxygen or oxygen delivery systems at residences so that fire departments may respond appropriately to the special safety hazards. The law requires the provider of the oxygen or an oxygen delivery system to inform the local fire department that oxygen or an oxygen delivery system is in a patient’s home. If the patient or the patient’s authorized representative refuses to authorize written notice, then the patient is obligated to give the notice.

A person who fails to notify the local fire department, as stated above, is a disorderly person and is subject to fines and other penalties under the law.

By checking “I consent,” you, the patient, or the patient’s authorized representative if the patient is incompetent, acknowledge that the provider of this oxygen or oxygen delivery system has provided you with information regarding the notification requirements of this law and that you authorize the provider to notify the local fire department of the delivery. By checking “I do not consent” on the authorization form, or if you fail to return the form, YOU must notify the local fire department that there is oxygen or an oxygen delivery system in your home.

Patient’s Name:  ______________________________________

Address:             ______________________________________

                           ______________________________________

Telephone:         ______________________________________

Name of fire department or company: ______________________________________

Provider’s Name: ______________________________________

Address:               ______________________________________

                              ______________________________________

                                  
Telephone:           ______________________________________

_______    I CONSENT AND AUTHORIZE THE PROVIDER TO GIVE NOTIFICATION

_______    I DO NOT CONSENT

Signed:  _______________________             Date: _______________________

Printed name, if authorized representative: _________________________________

Witness: _________________________________

               Sign and return this fyorm to the provider at the address listed above.

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