Home Phototherapy Order Packet - daavlin.com · Completed “Home Phototherapy Patient Order Form” Completed “Assignment of Benefits Form” Signed and initialed “Terms & Conditions

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

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 7, April 2010

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

To place your order, follow the 5 Steps below. Please print clearly. For assistance, call our representatives at 1-800-322-8546.

STEP

1Patient Name_____________________________________ Phone________________________

Address_________________________________________ Email_________________________

City________________________________ State_______ Zip Code_____________________

Date of Birth__________ Gender: Male___ Female___ Physician Name___________________

Skin Condition: Psoriasis_____ Vitiligo_____ Eczema_____ Other:_______________________

How did you hear about Daavlin? Doctor_____ Website_____ Magazine Ad_____ NPF______ VSI_____

Psoriasis Cure Now_____ Google Search_____ Facebook_____ Other_____________________________

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

M Series 10

1 Series 4

DermaPal 1

STEP 2

Circle the desired model and lamp

quantity.

PatientInfo:

STEP

3Circle the lamp type.

(Note: This must also be indicated

on your Rx)

NarrowBand UVB

BroadBand UVB

UVA

Other: (Please Specify)

____________________

Integrated Dosimetry

Digital Timer

Please Note: If required by your prescription,

FlexRx: Exposure Limiting Software

may be added to either of these control systems.

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 ($150)____

STEP 4Circle the control system.

STEP

5Confirm

the order, shipping & paymentmethod.

Payment Method: Please 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 11, Sept. 2010

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

Primary Insurance

HSLS0006, Rev 4, April 2010

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 6, Sept 2010

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 5).

• Upon delivery to your home, you agree to visibly inspect the packaging and to note any visible damage on the freight receipt prior to accepting the delivery.

• Upon opening, if you notice any damage that was concealed by the packaging, you agree to notify Daavlin within two business days of the product being delivered to your home.

• 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 1, April 2010

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 1, April 2010

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

Sample 1

LIT0034, Rev 1, April 2010

In order to obtain approval for Home Phototherapy Equipment, insurance payors require a letter or statement of medical necessity. Here are 2 samples. The letter should be written and signed by the

prescribing physician and should be printed on his or her official stationery or letterhead.

Sample 2

To Whom It May Concern:

John Doe has been under my care for ___ years for the treatment of generalized intractable psoriasis. The patient has had psoriasis for many years, which has been recalcitrant to all standard treatment methods. His percentage of BSA is __%, and he has previously tried ___ and ___ with no success. He has used ultraviolet light therapy, and has had significant improvement. Therefore, it is medically necessary for Mr. Doe to continue to undergo treatment with ultraviolet light. This will probably need to be undertaken for several months at a time throughout his life to maintain a state of remission. A home unit is necessary since treatment in a physician’s office would require a ___ hour round trip car ride to the closest center three times weekly. This would impose an unnecessary hardship on the patient, as his work schedule directly conflicts with the center’s hours of operation.

Therefore, I am prescribing a Daavlin Narrowband UVB home phototherapy unit. This unit is FDA compliant, and has the same healing potential as the ultraviolet units used in psoriasis 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.

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

Sincerely,

John Smith MD

To Whom It May Concern:

I am currently following Jane Doe. She is a patient with severe psoriasis, primarily of the arms and legs. This patient has had psoriasis for the past ___ years. Her percentage of BSA is ___% and she has previously tried ___ and ___ with little success. She has had a series of treatments with Narrowband UVB light, which was successful in clearing her psoriasis. The psoriasis has recurred and she has re-started her outpatient therapy.

Because of the severity and extent of her skin condition, she will most likely require ultraviolet light therapy intermittently for the rest of her life. That is why I have prescribed a Daavlin Narrowband UVB home phototherapy unit. This will enable her to maintain a state of remission and get the treatment she needs. The unit is FDA compliant and is safe and easy to use under my consultation.

Jane Doe’s work precludes regular visits to the psoriasis treatment center because of the hours of operation. I feel that it would be in Ms. Doe’s best interest and cost effective for the insurance company if she were to procure an ultraviolet light source for home use.

I would be happy to forward any supporting material or answer and questions you may have.

Sincerely,

John Smith MD