Would you like to place an order using Daavlin’s

Free Insurance Assistance Program?

Would you like to place an order to purchase

a Home Phototherapy unit out-right?

HSLS0005, Rev 8, Jan 2012

At Daavlin, we connect each patient with a Patient Account Specialist who will personally handle every aspect of your order from start to finish. Whether

using your medical insurance or purchasing a home unit out-right, our staff is friendly, professional and will assist you every step of the way!

Whether you choose to purchase your unit with cash, personal check, money order or credit card, we can quickly and easily process your order. Please submit the following information:

Completed “Home Phototherapy Patient Order Form” Signed and initialed “Terms & Conditions of Sale Agreement” Your prescription (Must state which lamp type - NB UVB, BB UVB or UVA)

Fax the information to 419-636-7916, mail to the address above, or email it to your Patient Account Specialist. All patient paperwork is kept confidential. Once we receive your information and payment, we will process your order immediately. If you have any questions or require immediate assistance, call Daavlin at 800-322-8546 .

If so, let us do the work for you! Daavlin has over 14 years of experience in insurance and medicare reimbursement for home phototherapy equipment. From getting pre-authorization to filing the claim, we will coordinate the details of your order with you, your doctor and your insurance company.

To take advantage of Daavlin’s Free Insurance Assistance Program, please submit:

Completed “Home Phototherapy Patient Order Form” Completed “Assignment of Benefits Form” Signed and initialed “Terms & Conditions of Sale Agreement” An enlarged copy of the front and back of your insurance card Your prescription (Must state which lamp type - NB UVB, BB UVB or UVA) A letter or statement of medical necessity (Examples attached)

Fax the information to 419-636-7916, mail to the address above, or email it to your Patient Account Specialist. All patient paperwork is kept confidential. Once we receive your information, we will contact your insurance company, verify your coverage for a Home Phototherapy Unit, and contact you with our findings.

If you have questions or require immediate assistance, call Daavlin at 800-322-8546.Daavlin 7 SeriesHome Phototherapy Panel

Home Phototherapy Patient Packet Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

To place your order, follow instructions below. Please print clearly. For assistance, call our representatives at 1-800-322-8546.

Home Phototherapy Patient Order Form Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

To place your order, follow the 6 Steps below. Please print clearly. For assistance, call our representatives at 1-800-322-8546.

STEP

1

Patient Name__________________________________ Phone________________________

Address________________________________________ Email_________________________

City_____________________________ State_______ Zip Code_____________________

Date of Birth________ Gender: Male___ Female___ Physician ___________________

Skin Condition: Psoriasis Vitiligo Eczema Other:___________________

How did you hear about Daavlin? Doctor Website Magazine Ad NPF VSI

TalkPsoriasis Internet Search Facebook Twitter Other____________________

PatientInfo:

STEP

3Circle

the lamp type.

I hereby confirm that the above order is accurate and complete to the best of my knowledge. I understand that a prescription, letter of medical necessity and Daavlin’s

Terms and Conditions of Sale Agreement must accompany all orders.

Signature (Required)__________________________________Date________________

Select a Shipping Method: Standard Delivery (Free) White Glove Delivery ($160)

STEP 4Circle the control system.

STEP

6Confirm

the order, shipping & paymentmethod.

Payment Method: Verify my insurance benefits & then contact me Personal Check

Mastercard Visa Discover American Express Expiration Date_____________

Acct#____________________________________________ 3 Digit V Code (on back of card)___________

HSLS0002, Rev 13, Jan 2012

(Note: This must also be indicated on your

prescription)

STEP

5Circle any

accessories you wish to

order.

Circle the desired model and lamp

quantity.

STEP 2

UV Series 24 16 12

12 10 8

7 Series 6 no doors 6 + reflective doors

4 no doors 4 + reflective doors

2 Series 8 4 + reflective doors 4

4 Series 10 20

M Series 10

1 Series 4

DermaPal 1

Distance Minder $130

1 Series Stand $150

7 Series Castors $50

7 Series Wall Mount $20

M Series Table $310

Fitover Glasses $8.50

Regular Glasses $9.50

Extra Goggles $7.50

Integrating Dosimetry

(not available on DermaPal)

Digital Timer

Please Note: If required by your

prescription, FlexRx: Exposure Limiting Softwaremay be added

to either of these control systems.

(FlexRx is not available

on DermaPal)

NarrowBand UVB

BroadBand UVB

UVA

UVA-1

Other: (Please Specify)

_________________

Assignment of Benefits Form Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

Primary Insurance

HSLS0006, Rev 5, Jan 2012

Secondary Insurance

Patient Name___________________________ Date of Birth__________ Phone_______________________

I authorize Daavlin to acquire medical benefits for Durable Medical Equipment on my behalf.

Signature (Required)______________________________________________Date_____________________

Name of Policy Holder_________________________________________________________________

Policy Holder’s Address ( Check here if same as Patient)____________________________________

____________________________________________________________________________________

Phone Number_____________________________Relationship to Patient: Self Spouse Parent

Date of Birth__________________Employer / School Name___________________________________

Insurance ID Number _________________________________________________________________

Insurance Group / Plan Number_________________________________________________________

Insurance Company___________________________________________________________________

Insurance Company Address____________________________________________________________

Insurance Company Phone Number______________________________________________________

Name of Policy Holder_________________________________________________________________

Policy Holder’s Address ( Check here if same as Patient)____________________________________

____________________________________________________________________________________

Phone Number_____________________________Relationship to Patient: Self Spouse Parent

Date of Birth__________________Employer / School Name___________________________________

Insurance ID Number _________________________________________________________________

Insurance Group / Plan Number_________________________________________________________

Insurance Company___________________________________________________________________

Insurance Company Address____________________________________________________________

Insurance Company Phone Number______________________________________________________

Terms & Conditions of Sale Agreement Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

• I confirm that I have received a copy of Daavlin’s HIPPA Privacy Policy................................................................................. ( Initials Required)

• I confirm that I have received a copy of Daavlin’s Patient Responsibilities and Patient Bill of Rights Policy............. ( Initials Required)

Terms & Conditions

of Sale Agreement

HSLS0004, Rev 8, Jan 2012

Please read the following information carefully and sign where designated to indicate your understanding and acceptance of the terms and conditions of this agreement. For assistance, call our representatives at 1-800-322-8546.

• Daavlin phototherapy devices are sold only by the prescription of a licensed physician. If a prescription has not been provided, you agree to do so prior to finalizing the sale.

•You agree to use your phototherapy device only in the manner in which it was intended. This includes following your physician’s instructions, scheduling periodic follow-up examinations and wearing protective goggles during treatments. Minor patients for whom this unit is prescribed are required to be under the supervision of a parent or guardian who understands

the use of the device and assumes full responsibility of the minor.

• There is no obligation to purchase when Daavlin verifies your insurance benefits and eligibility. However, once you have instructed Daavlin to process your order, payment in full of the agreed upon price becomes your responsibility. You understand that unmet deductibles, co-pays and changes in plan benefits can sometimes affect the amount of reimbursement you receive and you agree to pay the difference between the agreed upon price and the amount of your insurance reimbursement.

• If your device has not yet been paid in full, and your insurance company sends its payment to you instead of to Daavlin, you agree to forward this payment to Daavlin within five business days of receipt.

• Daavlin’s free “standard” delivery only includes carriage of the device to the ground floor door of your home. If you desire additional service, such as a stair carry or transport to the interior of your home, you must select “White Glove Delivery” on the Patient Order Form (under Step 6).

• Upon delivery to your home, you agree to inspect the package and to note any damage on the freight receipt prior to accepting the delivery. If you are unable to fully inspect the product before signing off on the delivery, you agree to indicate “Further Inspection Required - Concealed Damage Possible” on the freight receipt and to notify Daavlin within two business days of the product being delivered, if any damage is present.

• You agree that you have read and fully understand the size and weight of the device and that you have space to accommodate it. Further, you confirm your understanding that some larger devices may require a special electrical outlet and that you may have to have this wiring installed for the device to operate. ( Information on size, weight and electrical requirements can be found on our web site at www.daavlin.com or you may call a Daavlin representative at 1-800-322-8546).

• You agree that your order must be paid in full before your unit will be shipped and that all sales are final.

I understand, as the purchaser, that signing this document constitutes my understanding and agreement to the terms and conditions contained herein, which are applicable to the purchase of Daavlin phototherapy equipment.

Patient Name (Please Print)___________________________________________________________________

Signature (Required)___________________________________________________Date__________________

Please initial in the locations provided to indicate your receipt of the following forms:

HIPPA &Bill of RightsConfirmation

HIPPA Privacy Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.

Payment. You health information may be used to seek payment from your health plan, from other sources of coverage, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information regarding the medical condition being treated.

Health care operations. Your health information may be used, as necessary, to support the day-to-day activities and management of Daavlin. For example, information on the equipment you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Individual Rights

You have certain rights under the federal privacy standards. These include:• The right to request restrictions on the use and disclosure of your protected health information• The right to receive confidential communications concerning your medical condition and treatment• The right to inspect and copy your protected health information• The right to amend or submit corrections to your protected health information•The right to receive an accounting of how and to whom your protected health information has been disclosed• The right to receive a printed copy of this notice

Daavlin is required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.We are also required to abide by the privacy policies and practices that are outlined in this notice.As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon, request, we will provide you with the most recently revised notice.

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

DaavlinP.O. Box 626Bryan, Ohio 43506419-636-6304

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.

You will not be penalized or otherwise retaliated against for filing a complaint.

You many also use the above name and address to contact us for further information concerning our privacy practices.

THIS NOTICE IS EFFECTIVE ON OR AFTER JANUARY 22, 2009.

QUAL0057, REV 2, Jan 2012

Patient Responsibilities & Patient Bill of Rights

PATIENT RESPONSIBILITIES:

To ensure the finest care possible, you must understand your role in your health care. As a customer of Daavlin, you are responsible for the following:

1. To provide complete and accurate information at all times, including but not limited to: Insurance Information and any/all Insurance changes; up to date name, address, and telephone numbers; up to date Medical information including diagnosis, physician information, changes in status or need, etc. 2. To request additional assistance or information on any issue with your order that you don’t fully understand.

3. To notify Daavlin when encountering any problems with your medical device.

4. To notify Daavlin of denial and/or restriction of the Daavlin privacy policy.

PATIENT BILL OF RIGHTS:

As an individual receiving medical devices from Daavlin you have the following rights:

1. To select those who provide your medical devices.

2. To be provided with legitimate identification by any person or persons entering your residence to provide delivery services or maintenance of your medical device.

3. To be provided with adequate information from which you can give your informed authorization for the commencement of your order, the continuation of your order, the transfer of your order to another provider, or the termination of your order.

4. To be advised, before the order is shipped, of the extent to which payment for the medical device may be expected from Medicare/Medicaid, insurance, or your liability for payment, billing cycles and changes in payment.

5. To have your privacy respected at all times and to be treated with respect, consideration, and recognition of dignity and individuality.

6. To express concerns or grievances or recommend modifications to your home care service without fear of restraint, interference, coercion, discrimination, or reprisal. You may contact any of the following organizations with grievances:

Ohio Medicare (800) 589-7337Ohio Medicaid (800) 324-8680 #2ACHC (919) 785-1214

7. To expect that information received by Daavlin will be kept confidential and shall not be released without written authorization.

8. The right to review Daavlin’s Privacy Practices

9. To receive the appropriate customer service in a professional manner without discrimination

QUAL0058, REV 2, Jan 2012

Sample Letter of Medical Necessity Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

Sample Letter

LIT0034, Rev 2, Jan 2012

In order to obtain approval for Home Phototherapy Equipment, insurance payors require a letter or statement of medical necessity. Here is a sample that may be provided to the doctor if needed. The

letter should be written and signed by the prescribing physician and should be printed on his or her official stationery or letterhead.

Date: ______________

To Whom It May Concern:

_______________________ is a _______ year old patient who has been under my care for ______ years for the treatment of ____________. The percentage of this patient’s body surface affected (BSA) by this disease is ______%. It has been recalcitrant to many treatment methods, as the patient has previously been treated with ____________ with little or no success. However, the patient has shown improvement from ultraviolet light / sunlight.

Because of the severity and extent of this skin condition, I have determined that it is medically necessary for this patient to continue treatment with ultraviolet light. Ultraviolet light therapy is a very safe and effective treatment, approved by the FDA. This patient will most likely require UV therapy intermittently for the rest of their life, therefore, a home phototherapy unit is the most cost effective option.

Treatment in a phototherapy center would require unnecessary travel and loss of productivity for the patient, and the cost to your insurance company of on-going, in-office therapy would be far greater than the one-time purchase of a home unit. In addition, recent studies have shown extremely high patient compliance rates with home phototherapy, as patients are much less likely to miss treatments when the device is readily available to them.

For these reasons, I have prescribed a Daavlin Narrowband UVB home phototherapy unit. This one-time purchase will enable the patient to reach and maintain a state of remission. This device is FDA compliant and has the same healing potential as the ultraviolet units used in medical centers, but was designed specifically for home use. It is easy and safe for the patient to operate after proper instruction and continued monitoring by me. I feel that this patient is reliable, motivated to get well, and able to understand and follow my directions.

If you have any questions, please do not hesitate to call me.

Sincerely,

Physician’s Signature____________________________ Physician’s Name (Printed)____________________________