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Let's Be Clear 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
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