physician approval / medical necessity form€¦ · physician approval / medical necessity form....
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Cell/Home Phone: (______)_____________ Patient e-mail____________________________________Insurance Company____________________________
PPhhysician Physician InformationInformation
Physician Name _____________________________________ Practice: ________________________________________ NPI # ____________________________
Office Email: ___________________________________________ Address ________________________________________________________________________
City ______________________ State ________ Zip ________________ Phone (_______) _____________________ Fax (________) _________________
SignSignatureature
Date _______________________________________________ (Stamps are not acceptable) Physician Signature _________________________________________________________
Patient Information
Name _____________________________________________________________ Middle Initial ____ Birthdate _____ /______ /__________
Address _____________________________________ City __________________________State ____________ Zip _____________ Gender: M F
Hands/Feet
4 Lamp-NB-UVB
Scalp/Spot Treatment
2 Lamp—NB-UVB
Full Body10 Lamp—6 ft.
NB-UVB with side
light panels
Physician Approval / Medical Necessity Form
National Biological Corp. • 23700 Mercantile Road • Beachwood, OH 44122 • Phone (216) 831-0600 • Fax (216) 765-0271 • www.phototherapyexperts.com
Panosol 3D®
Handisol II®
Patient Name:
The reason for this prescription concerns my patient'swhich affects more than of the patient's body surface area.
Numerous medications have been tried and failed including:
As this diagnosis is usually a life-long condition that requires long-term maintenance to prevent
future flare-ups, my patient will likely require UV light treatment for indefinite use with an on-
going maintenance schedule. Treatment frequency of 3 times per week is required with likely
moderation during the summer months.
I am recommending an FDA listed due to its ease of use, effectiveness
and relative safety due to its prescription controlled timer where I can specifically guide the patient’s use through periodic visits to my office to help control the patient’s treatment regimen. I feel as though my patient is capable of operating the Home UV device and staying within the prescribed exposure times.Home UV light would cost the health plan less than the same treatment at a clinic, as this is
a chronic condition generally requiring a minimum of additional treatments over the next
12 months. Each in-clinic visit will cost yielding a minimum yearly treatment cost of more
than whereas a one-time cost of a Home UV device is approximately
-
Home Phototherapy Systems
Fitzpatrick Skin Type
I
II
III
IV
Dermalume 2X™
Other NB-UVB Models Available:
16 Lamp—6 ft. NB-UVBFoldalite III® - Folding Unit
Panosol II® Panel 4 Lamp—6 ft. NB-UVB
8 Lamp—2 ft. NB-UVB
Hand/Foot II™ 8 Lamp—NB-UVB
Dermalight 90® - Scalp NB-UVB
Other: (UVA, UVA1, BB-UVB) ___________________
Diagnosis Code (ICD-10)
____/____/______
______________________
Patient has a history ofwhich requires immediate treatment to control the disease. The area of involvement includes:
HCPCS Code
_____________________
Signature
Physician Information
(DOB):
DF-155-W Rev 003
V
VI