Let’s Be Clear...

HSLS0005, Rev 10, May 2013

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!

Here’s what we need to begin your order:

Patient - 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

Prescriber - Either a completed “Doctor’s Written Order Form” OR a Prescription and Letter of Medical Necessity

Five to ten pages of relevant chart notes

Simply fax the information to 419-636-7916, mail to the address above, or email it to your phototherapy@daavlin.com. 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 now at 1-800-322-8546. Our Account Specialists, Tech Support Team and on-staff Dermatology Nurse are happy to assist you!

Our commitment to you starts...Now!

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.

Our commitment to you starts...Now!

We’re here to do the work for you!

Daavlin has over 15 years of experience in insurance and

medicare reimbursement for home phototherapy

equipment.

Insurance networks are no problem!

From getting the pre-authorization to filing

the claim, we will coordinate the details of your order with

you, your doctor and your insurance company.

Helpful Hint...To reach your Patient Account Specialist:

1. Dial 1-800-322-8546.

2. Use the 1st letter of the patient’s last name for the extension of the correct specialist.

A - E........dial x 217 F - Le.....dial x 218Lf - Roe...dial x 212 Rof - Z...dial x 222

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 either a prescription and letter of medical necessity OR

a Doctor’s Written Order Form (attached to this packet) AND Daavlin’s Terms and Conditions of Sale Agreement must accompany all orders.

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 16, April 2013

(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

4 Series 10 20

M Series 10

1 Series 4

Levia 1

DermaPal 1

Integrating Dosimetry(Integrating Dosimetry is not

available on Levia or DermaPal)

Digital Timer

Please Note: If required by your

prescription, FlexRx: Exposure Limiting Software

may be added to either of these control

systems.(FlexRx is not available

on Levia or DermaPal)

NarrowBand UVB

UVA

UVA-1

Other: (Please Specify)

_________________

UVB Select - Levia Only

Distance Minder $130

1 Series Stand $150

4 Series UVB Filter $700

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

DermaClean Wipes $11

Select Shipping Method: Standard Delivery in Contiguous 48 States (Free) White Glove Delivery ($200)

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

Terms & Conditions

of Sale Agreement

HSLS0004, Rev 10, April 2013

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.

• Only orders within the contiguous 48 states qualify for Daavlin’s free delivery. Hawaiian and Alaskan deliveries will incur additional shipping charges. Daavlin will provide shipping quotes based upon the delivery address.

• 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 location provided to indicate your receipt of the following forms:

DocumentReceipt

Confirmation

I confirm that I have received:

• A copy of Daavlin’s HIPAA Privacy Policy / Patient Responsibilities / Patient Bill of Rights Policy

• A copy of Daavlin’s Medicare Standards

Daavlin is required to provide these forms to each patient. The forms are yours to review and keep for your records.

Please Initial Here to Confirm Receipt

HIPAA Privacy Policy:

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 RightsYou 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.

QUAL0057, REV 4, April 2013

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

Patient Copy Keep for Your Records!

Medicare Standards:

MEDICARE DMEPOS SUPPLIER STANDARDS

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain andretain 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, 200923. 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, 200927. 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

Patient Copy Keep for Your Records!

Doctor’s Written Order For Home Phototherapy

Fax To: 419-636-7916

First Name _____________________ Last Name _________________________ Middle Initial ____ DOB ___/___/___

Address _________________________________________ Phone _________________________ Gender: M F

City _____________________________ State ______ Zip ____________ Alt Phone_____________________________Patie

nt:

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.

Physician Signature (Required)_________________________________________________Date______________________

HSLS0019, Rev 2, April 2013

Physician Name _______________________________

Practice ______________________________________

NPI# _________________________________________

Address _____________________________________

City ____________________ State ____ Zip _______

Phone (____)____________ Fax (____)____________

Pres

crib

ing

Doc

tor:

Sign

atur

e:

ICD-9: Description:

696.1 Psoriasis

709.01 Vitiligo ______ ___________________ Estimated Length of Need: ___ Months (99 = Lifetime)

Body Area Affected (Check all that apply) 3 % - 10 % (Moderate) Hands (2 %) > than 10 % (Severe) Feet (2 %) Other: __________ % Scalp (9 %) Cumulate______________________________ List Previous Treatments: Was it Effective?

______________________________ Yes No

______________________________ Yes No

______________________________ Yes No

Date Treatment Began: ____ / ____ / ____ Has patient ever been treated w/ UV Light Therapy in the past? (Either in the office or at home) Yes No

If yes, did the patient benefit from it? Yes No

Is the patient and/or caregiver reliable, motivated and able to adhere to instructions? Yes No

Reason for Home Use: (please check all that apply) Therapy is Considered Long-Term Distance and Travel Time to Office Co-pay Cost of Frequent In-Office Visits Unable to Take Time Away from Work or School Other:____________________________________

HCPCs: Description:

E0691 Hand-held Phototherapy Wand for

Scalp, Spot Treatment or Travel

E0691 2’ Phototherapy Panel for Hands,

Face, and Other Localized Areas

E0694 6’ Phototherapy Panel with

Multi-Directional Lamps for Larger

Treatment Areas

E0694

6’ Phototherapy Walk-In Cabinet for

Full-Body Treatment

E1399

Multi-Directional Hand and Foot

Phototherapy Unit

Dia

gnos

is &

Sta

tem

ent

of M

edic

al N

eces

sity

:

99

Hom

e P

hoto

ther

apy

Pro

duct

:

Please check only1 item per form.

Prescribed Lamp Type: NB UVB UVA _______

FlexRx (Exposure Limiting Software): Yes No If yes, how many exposures?FlexRx can be prescribed in increments of 10 up to 250; the default amount is 40.

Uni

t Inf

o:

Note: FlexRx is not available on DermaPal hand-held units.

Rx

(Stamps are not acceptable)

For Office Use Only Daavlin PO Box 626 Bryan, OH 43506

Edgepark Medical Supplies 1810 Summit Commerce Park Twinsburg, OH 44087

Other________________________

Billi

ng E

ntity

:

Prescriber Instructions: This form can be used in place of a Prescription and Letter of Medical Necessity to order Daavlin home phototherapy products. (For Levia orders, please use the

Levia version of this form.) All fields are required. Call 800-322-8546 for assistance.

Skin Dose Increase Fequency Type (mJ/CM2) (%) (Every___days)

I 90 15% Every 2 days

II 150 15% Every 2 days

III 180 15% Every 2 days IV 230 15% Every 2 days V 250 15% Every 2 days

Doctor’s Written Order For Levia Phototherapy

Fax To: 419-636-7916

First Name _____________________ Last Name _________________________ Middle Initial ____ DOB ___/___/___

Address _________________________________________ Phone _________________________ Gender: M F

City _____________________________ State ______ Zip ____________ Alt Phone_____________________________Patie

nt:

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.

Physician Signature (Required)_________________________________________________Date______________________

HSLS0024, Rev 1, May 2013

Physician Name _______________________________

Practice ______________________________________

NPI# _________________________________________

Address _____________________________________

City ____________________ State ____ Zip _______

Phone (____)____________ Fax (____)____________

Pres

crib

ing

Doc

tor:

Sign

atur

e:

ICD-9: Description:

696.1 Psoriasis

709.01 Vitiligo ______ ___________________ Estimated Length of Need: ___ Months (99 = Lifetime)

Body Area Affected (Check all that apply) 3 % - 10 % (Moderate) Hands (2 %) > than 10 % (Severe) Feet (2 %) Other: __________ % Scalp (9 %) Cumulate______________________________ List Previous Treatments: Was it Effective?

______________________________ Yes No

______________________________ Yes No

______________________________ Yes No

Date Treatment Began: ____ / ____ / ____ Has patient ever been treated w/ UV Light Therapy in the past? (Either in the office or at home) Yes No

If yes, did the patient benefit from it? Yes No

Is the patient and/or caregiver reliable, motivated and able to adhere to instructions? Yes No

Reason for Home Use: (please check all that apply) Therapy is Considered Long-Term Distance and Travel Time to Office Co-pay Cost of Frequent In-Office Visits Unable to Take Time Away from Work or School Other:____________________________________

Dia

gnos

is &

Sta

tem

ent

of M

edic

al N

eces

sity

:

99

HCPCs : Description:

E1399 Levia Personal Targeted UVB Home Phototherapy System

Rxby

Prod

uct:

I 90 15% Every 2 days

II 150 15% Every 2 days

III 180 15% Every 2 days

IV 230 15% Every 2 days

V 250 15% Every 2 days

IV 280 15% Every 2 days

Choose one:

Or Enter a Custom Regimen

I to IV 5 - 995 0 - 50% Every 1 - 99 days

Sele

ct a

Tre

atm

ent R

egim

en:

(Stamps are not acceptable)

For Office Use Only Daavlin PO Box 626 Bryan, OH 43506

Edgepark Medical Supplies 1810 Summit Commerce Park Twinsburg, OH 44087

Other________________________

Billi

ng E

ntity

:

Prescriber Instructions: This form can be used in place of a Prescription and Letter of Medical Necessity to order Levia home phototherapy units. (For all other home phototherapy orders,

please use the Daavlin version of this form.) All fields are required. Call 800-322-8546 for assistance.