Home Phototherapy Order 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.

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!

Let’s Be Clear... Our commitment to you starts...Now! We’re here to do the work for you! Here’s what we need to begin your order:

Daavlin has over 18 years of From the Patient - experience with insurance Completed “Home Phototherapy Patient Order Form” and Medicare reimbursement Signed and initialed “Terms & Conditions of Sale Agreement” for home phototherapy equipment. From the Prescriber - Insurance networks are Completed and signed “Physician’s Written Order Form” no problem! Just five to ten pages of relevant chart notes From getting the Simply send these four items to Daavlin and we can get started! pre-authorization to filing the claim, we will coordinate • Fax to 419-636-7916 or 419-636-1739 the details of your order with • Mail to Daavlin, PO Box 626, Bryan, OH 43506 you, your doctor and your • Email to [email protected] insurance company. • Fill out the online version at www.daavlin.com

Helpful Hint...To reach your All patient paperwork is kept confidential. If you request insurance Patient Account Specialist: processing, once we receive your information we will contact your 1. Dial 1-800-322-8546. insurance company, verify your coverage and contact you with our findings! 2. Use the 1st letter of the patient’s last name for the extension of If you have questions or require immediate assistance, call Daavlin the correct specialist. now at 1-800-322-8546. Our Patient Account Specialists and our A - De ...... dial x 217 Df - H .....dial x 218 Technical Support Team are happy to assist you! I - M ...... dial x 231 N - Sh ....dial x 212 Si - Z ...... dial x 222 Our commitment to you starts...Now!

HSLS0005, Rev 13, Sept 2015 Home Phototherapy Patient Order Form Fax To: 419-636-7916 Mail To: PO Box 626 Bryan, OH 43506

To be filled out by the PATIENT. To order, fill in the info below. Please print clearly. For assistance, call our representatives at 1-800-322-8546.

Patient Name______Phone______Address______City______State______Zip______Email______Alternate Phone______

Patient Info: Patient Date of Birth______Gender: Male___ Female___ Physician ______Skin Condition: Psoriasis Vitiligo Eczema Other: ______

Free Insurance Assistance: We will verify your insurance benefits & contact you before processing ( Insurance Info below is required )

Or Purchase Without Insurance Using: Check Credit Card Daavlin Payment Plan ( 50% Deposit Required)

Name of Primary Insurance Policy Holder______Date of Birth______Policy Holder’s Address ( or check here if same as patient)______Phone Number______Circle relationship to patient: Self Spouse Parent Primary Insurance Company______Employer______Insurance ID Number ______Group / Plan Number______Primary Insurance Company Phone Number (Found on insurance card)______

Name of Secondary Insurance Policy Holder, if any______Date of Birth______Policy Holder’s Address ( or check here if same as patient)______Phone Number______Circle relationship to patient: Self Spouse Parent

Info for Free Insurance Assistance: Insurance Free for Info Secondary Insurance Company______Employer______Insurance ID Number ______Group / Plan Number______Secondary Insurance Company Phone Number (Found on insurance card)______

Circle Lamp Circle Lamp Circle Lamp Quantity: Quantity: Quantity: Digital Timer 8 lamps 12 lamps 10 lamps 10 lamps 16 lamps 20 lamps 12 lamps 24 lamps Dosimetry DermaPal 1 Series 7 Series UV Series 4 Series Levia M Series (Not available on Hand-held Wand, Small Panel, Six Foot Tall, Panel Style, Six Foot Tall, Cabinet Style, Four Foot Tall Panel, Targeted Spots, Hand/Foot Light Box DermaPal or Levia) Scalp & Spots Hands, Feet, Etc. Full-Body Treatment Full-Body Surround Medium Areas Fiber-Optic Scalp Lamps in Base & Hood Product Choice: Product Controller Choice: Controller

It is important to understand the size and weight Standard Delivery...... Cost is included in the price of the unit when shipped in the contiguous 48 States, of your prescribed device and the shipping and consists of basic carriage to a ground floor door of your home or garage. process, as all sales of medical devices are final. White Glove Delivery..... Large items (7 Series or UV Series) only. Cost is $500 - Includes inside delivery to the Please discuss these details with your Patient interior of your home, stair-carry if necessary, and removal of packaging. Account Specialist by calling 1-800-322-8546.

Important! Here are the 4 items Daavlin needs to begin processing your order: Patient Order Form (This page) Terms & Conditions Form (Page 3) Physician’s Written Order (Dr. must complete) Chart Notes (If using insurance)

I confirm that the above information is accurate and complete to the best of my knowledge. I understand that a Physician’s Written Order Form, chart notes (if using insurance) and Daavlin’s Terms & Conditions Form must accompany my order. By providing my insurance information above, I authorize Daavlin to acquire medical benefits for Durable Medical Equipment on my behalf. I agree to follow my prescriber’s instructions for proper use of this medical device. Shipping & Confirmation: Signature (Required)______Date______

HSLS0002, Rev 19, Dec 2013 Terms & Conditions of Sale Agreement Fax To: 419-636-7916 Mail To: PO Box 626, Bryan, OH 43506

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.

Terms & • Daavlin phototherapy devices are sold only by the written order of a licensed physician. If a Conditions written order has not been provided, you agree to do so prior to finalizing the sale. of Sale • You agree to use your phototherapy device only in the manner in which it was intended. This Agreement 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. • Only orders within the contiguous 48 states qualify for Daavlin’s “Standard” delivery. Hawaiian and Alaskan deliveries will incur additional shipping charges. Daavlin will provide shipping quotes based upon the delivery address. • Daavlin’s “Standard” delivery (at no extra cost) only includes carriage of the device to the ground floor door of your home or garage. 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. • 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 all sales of prescription medical equipment are non-returnable.

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 location provided to indicate your receipt of the following forms:

I confirm that I have received: Document Receipt • A copy of Daavlin’s HIPAA Privacy Policy / Patient Responsibilities / Patient Bill of Rights Policy Confirmation • A copy of Daavlin’s Medicare Standards Please Initial Here to Confirm Receipt Daavlin is required to provide these forms to each patient. The forms are yours to review and keep for your records.

HSLS0004, Rev 11, Dec 2013 3 Patient Copy HIPAA Privacy Policy: Keep for Your Records!

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) 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. “HIPAA” 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: Daavlin, P.O. Box 626, Bryan, Ohio 43506. Phone 419-636-6304. 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.

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) 589-7337 Ohio Medicaid (800) 324-8680 #2 ACHC (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.

QUAL0057, REV 4, April 2013 Patient Copy Medicare Standards: Keep for Your Records!

MEDICARE DMEPOS SUPPLIER STANDARDS

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business, with visible signage. The location must be at least 200 square feet and contain space for storing records. 8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. 11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicarecovered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it. 21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. 26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009 27. A supplier must obtain oxygen from a state- licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f). 29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers. 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.

QUAL0058, REV 3, July 2012 Physician’s Written Order For Office Use Only : Daavlin PO Box 626 Bryan, OH 43506 For Home Phototherapy Fax To: 419-636-7916 Other: ______Rx Prescriber Instructions: This form is a Prescription and Statement of Medical Necessity for Billing Entity ______Daavlin home phototherapy products. (For Levia orders, please use the Levia version of ______this form.) All fields are required for insurance approval. Call 800-322-8546 for assistance.

First Name ______Last Name ______Middle Initial ____ DOB ____/____/____

Address ______City______State______Zip______

Patient: Gender: M F Phone #______Alt Phone #______

Physician Name ______ICD-10 : Description / ICD-9 ICD-10 Code L40 . _____ Psoriasis 696.1 Must Be Indicated Practice ______L80 Vitiligo 709.01 ______. ____ Other: ______NPI# ______(See back for ICD -10 Code Quick Referrence Guide) Address ______Estimated Length of Need: ___99 Months (99 = Lifetime) City ______State ____ Zip ______Body Area Affected (Check all that apply)

Prescribing Physician: Prescribing Phone (____)______Fax (____)______3 % - 10 % (Moderate) Hands (2 %) > than 10 % (Severe) Feet (2 %) Other: ______% Scalp (9 %) HCPCs: Description: List Previous Treatments: Was it Effective? DermaPal: Hand-held treatment ______Yes No E0691 wand for scalp, spot treatment or ______Yes No travel. Includes comb attachment.

1 Series: Small, light-weight panel for ______Yes No E0691 hands, face, feet, elbows, or any other Date Treatment Began: ____ / ____ / ____ localized treatment area. Has patient ever been treated w/ UV Light Therapy in 7 Series / UV Series: Six foot tall unit the past? (Either in the office or at home) Yes No E0694 with multi-directional phototherapy If yes, did the patient benefit from it? Yes No lamps for large treatment areas.

Home Phototherapy Product: Home Phototherapy Is the patient and/or caregiver reliable, motivated and Other: of Medical Necessity: & Statement Diagnosis able to adhere to instructions? Yes No ______Reason for Home Use: (please check all that apply) Therapy is Considered Long-Term Prescribed Lamp Type: NB UVB UVA ______Distance and Travel Time to Office FlexRx (Exposure Limiting Software): Yes No Co-pay Cost of Frequent In-Office Visits Note: FlexRx is not If yes, how many exposures? available on DermaPal Unable to Take Time Away from Work or School Unit Info: FlexRx can be prescribed in increments of 10 up to 250; the default amount is 40. Other:______

I certify that I am the physician identified on this form. I have reviewed this Physician’s Written Order. Any statement on my letterhead attached hereto has also been reviewed and signed by me. I certify that this patient and/or caregiver is capable and will be trained on the proper use of the products prescribed on this Written Order. The patient’s record contains supporting documentation that substantiates the utilization and medical necessity of the product listed, and the physician notes and other supporting documentation will be provided upon request. I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient’s medical record. Signature: Physician Signature (Required)______Date______(Stamps are not acceptable)

HSLS0019, Rev 6, Sept 2015 L40 Psoriasis L40.0 Psoriasis vulgaris (Nummular psoriasis, Plaque psoriasis) Quick Reference Guide: L40.1 Generalized pustular psoriasis (Impetigo herpetiformis, Von Zumbusch) Commonly Used L40.2 Acrodermatitis continua L40.3 Pustulosis palmaris et plantaris Diagnosis / ICD-10 Codes L40.4 Guttate psoriasis L40.5 Arthropathic psoriasis (M07.0-M07.3*, M09.0*) L20 Atopic dermatitis / Eczema L40.8 Other psoriasis (Flexural psoriasis) L20.8 Other atopic dermatitis L40.9 Psoriasis, unspecified L20.9 Atopic dermatitis, unspecified L41 Parapsoriasis L21 Seborrhoeic dermatitis L41.0 Pityriasis lichenoides et varioliformis acuta L21.8 Other seborrhoeic dermatitis L41.1 Pityriasis lichenoides chronica L21.9 Seborrhoeic dermatitis, unspecified L41.3 Small plaque parapsoriasis L23 Allergic contact dermatitis L41.4 Large plaque parapsoriasis L23.0 Allergic contact dermatitis due to metals L41.5 Retiform parapsoriasis L23.1 Allergic contact dermatitis due to adhesives L41.8 Other parapsoriasis L23.2 Allergic contact dermatitis due to cosmetics L41.9 Parapsoriasis, unspecified L23.3 Allergic contact dermatitis due to drugs in contact with skin L42 Pityriasis rosea L23.4 Allergic contact dermatitis due to dyes L43 Lichen planus L23.5 Allergic contact dermatitis due to other chemical products L43.0 Hypertrophic lichen planus L23.6 Allergic contact dermatitis due to food in contact with skin L43.1 Bullous lichen planus L23.7 Allergic contact dermatitis due to plants, except food L43.2 Lichenoid drug reaction L23.8 Allergic contact dermatitis due to other agents L43.3 Subacute (active) lichen planus L23.9 Allergic contact dermatitis, unspecified cause L43.8 Other lichen planus L24 Irritant contact dermatitis L43.9 Lichen planus, unspecified L24.0 Irritant contact dermatitis due to detergents L44 Other papulosquamous disorders L24.1 Irritant contact dermatitis due to oils and greases L44.0 Pityriasis rubra pilaris L24.2 Irritant contact dermatitis due to solvents L44.1 Lichen nitidus L24.3 Irritant contact dermatitis due to cosmetics L44.2 Lichen striatus L24.4 Irritant contact dermatitis due to drugs in contact with skin L44.3 Lichen ruber moniliformis L24.5 Irritant contact dermatitis due to other chemical products L44.4 Infantile papular acrodermatitis [Giannotti-Crosti] L24.6 Irritant contact dermatitis due to food in contact with skin L44.8 Other specified papulosquamous disorders L24.7 Irritant contact dermatitis due to plants, except food L44.9 Papulosquamous disorder, unspecified L24.8 Irritant contact dermatitis due to other agents L50 Urticaria L24.9 Irritant contact dermatitis, unspecified cause L50.0 Allergic urticaria L25 Unspecified contact dermatitis L50.1 Idiopathic urticaria L25.0 Unspecified contact dermatitis due to cosmetics L50.2 Urticaria due to cold and heat L25.1 Unspecified contact dermatitis due to drugs in contact with skin L50.3 Dermatographic urticaria L25.2 Unspecified contact dermatitis due to dyes L50.4 Vibratory urticaria L25.3 Unspecified contact dermatitis due to other chemical products L50.5 Cholinergic urticaria L25.4 Unspecified contact dermatitis due to food in contact with skin L50.6 Contact urticaria L25.5 Unspecified contact dermatitis due to plants, except food L50.8 Other urticarial (Urticaria: chronic, recurrent periodic) L25.8 Unspecified contact dermatitis due to other agents L50.9 Urticaria, unspecified L25.9 Unspecified contact dermatitis, unspecified cause L63 Alopecia areata L28 Lichen simplex chronicus and prurigo L63.8 Other alopecia areata L28.0 Lichen simplex chronicus L63.9 Alopecia areata, unspecified L28.1 Prurigo nodularis L80 Vitiligo L28.2 Other prurigo L92 Granulomatous disorders of skin and subcutaneous tissue L29 Pruritus L92.0 Granuloma annulare L29.8 Other pruritus L92.8 Other granulomatous disorders of skin and subcutaneous tissue L29.9 Pruritus, unspecified L92.9 Granulomatous disorder of skin and subcutaneous tissue, unspecified L30 Other dermatitis L93 Lupus erythematosus L30.0 Nummular dermatitis L93.0 Discoid lupus erythematosus (Lupus erythematosus NOS) L30.1 Dyshidrosis [pompholyx] L93.1 Subacute cutaneous lupus erythematosus L30.2 Cutaneous autosensitization L93.2 Other local lupus erythematosus (Lupus: erythematosus profundus,panniculitis) L30.3 Infective dermatitis L94 Other localized connective tissue disorders L30.4 Erythema intertrigo L94.0 Localized scleroderma [morphea] (Circumscribed scleroderma) L30.5 Pityriasis alba L94.1 Linear scleroderma (En coup de sabre lesion) L30.8 Other specified dermatitis C84.8 Cutaneous T-cell lymphoma, unspecified L30.9 Dermatitis, unspecified L11.1 Transient acantholytic dermatosis [Grover’s Disease] Physician’s Written Order For Office Use Only : Daavlin PO Box 626 Bryan, OH 43506 For Levia Phototherapy Other: ______by Fax To: 419-636-7916 ______R Billing Entity ______x Prescriber Instructions: This form can be used in place of a Prescription and Letter of Medical ______Necessity to order Levia home phototherapy units only. (For all other home phototherapy orders, please use the Daavlin version of this form.) All fields are required. Call 800-322-8546 for assistance.

First Name ______Last Name ______Middle Initial ____ DOB ___/___/___

Address ______Phone ______Gender: M F

Patient: City ______State ______Zip ______Alt Phone______

Physician Name ______ICD-10 : Description / ICD-9 ICD-10 Code Must Be L40 . _____ Psoriasis 696.1 Indicated Practice ______L80 Vitiligo 709.01 ______. ____ Other ______NPI# ______

Address ______Estimated Length of Need: ___99 Months (99 = Lifetime)

City ______State ____ Zip ______Body Area Affected (Check all that apply) Prescribing Doctor: Prescribing Phone (____)______Fax (____)______3 % - 10 % (Moderate) Hands (2 %) > than 10 % (Severe) Feet (2 %) Other: ______% Scalp (9 %) HCPCs : Description: List Previous Treatments: Was it Effective?

E1399 Levia Personal Targeted UVB ______Yes No Product: Home Phototherapy System ______Yes No

Skin Dose Increase Fequency ______Yes No Choose Type (mJ/CM2) (%) (Every___days) one: Date Treatment Began: ____ / ____ / ____

I I 90 90 15% 15% Every Every 2 2 days days Has patient ever been treated w/ UV Light Therapy in

IIII 150150 15% 15% Every Every 2 2 days days the past? (Either in the office or at home) Yes No If yes, did the patient benefit from it? Yes No III 180180 15% 15% Every Every 2 2 days days Is the patient and/or caregiver reliable, motivated and IV 230 15% 15% Every 2Every days 2 of Medical Necessity: & Statement Diagnosis days able to adhere to instructions? Yes No V V 250 250 15% 15% Every Every 2 days 2 days Reason for Home Use: (please check all that apply) VI 280 15% Every 2 days Therapy is Considered Long-Term Distance and Travel Time to Office

Select a Treatment Regimen: Treatment Select a Or Enter a Custom Regimen Co-pay Cost of Frequent In-Office Visits

I to VI 5 - 995 0 - 50% Every 1 - 99 days Unable to Take Time Away from Work or School Other:______

I certify that I am the physician identified on this form. I have reviewed this Physician’s Written Order. Any statement on my letterhead attached hereto has also been reviewed and signed by me. I certify that this patient and/or caregiver is capable and will be trained on the proper use of the products prescribed on this Written Order. The patient’s record contains supporting documentation that substantiates the utilization and medical necessity of the product listed, and the physician notes and other supporting documentation will be provided upon request. I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient’s medical record. Signature: Physician Signature (Required)______Date______(Stamps are not acceptable)

HSLS0024, Rev 3, Sept 2015