physician approval / medical necessity form€¦ · physician approval / medical necessity form....

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