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Insurance Form

Patient Name:

Insurance Company/Plan:

Patient I.D. Number:


Description for Phototherapy Unit:

This is to certify that I am currently treating the above named patient for recurrent major depressions (DSMIV-R-296.3) with a seasonal pattern. This condition, known as Seasonal Affective Disorder, has been shown in many studies in the United States and Europe to respond to treatment with bright environmental light (phototherapy). Phototherapy is no longer considered experimental, but is a mainstream type of psychiatric treatment, described in the Task Force Report of the American Psychiatric Association: Treatment of Psychiatric Disorders, vol. 3, pages 1890-1896. In the above patient’s case, Seasonal Affective Disorder currently appears: __ to be an isolated psychiatric disorder or ___ exists concomitantly with a previously-diagnosed psychiatric disorder of other origins (phototherapy being an addition to current other treatments). In order to administer phototherapy adequately, a specialized lighting device, such as the one described on the attached invoice, is required. In this patient’s case, the use of such a device should be regarded as both a medical necessity and a preferred method of treatment for this disorder. Because of necessary treatment features as to time of day and duration of use, the patient’s possession of a home-use unit such as I have prescribed is a requirement for successful and practical therapy, and is, in my opinion, the most cost effective treatment alternative.

Code # and Diagnosis

DSM IV-296.3X - Major Depression, Recurrent

DSM IV-296.4X - Bipolar Disorder, most recent episode-Manic

DSM IV-296.5X - Bipolar Disorder, Depressed

DSM IV-296.6X - Bipolar Disorder, Mixed

DSM IV-296.8 – Bipolar Disorder, NOS

DSM IV – 296.90 – Mood Disorder, NOS: Seasonal Affective Disorder

DSM IV-311.00 – Depressive Disorder, NOS

These procedures conform to April 1993 U.S. Public Health Service-Agency for Health Care Policy and research guidelines for management of this disorder.

Publication # and Title

AHCPR93-0551-Depress: Guideline Vol. 2

AHCPR93-0553-Depress: Patient Guide

Prescribing Doctor/Date:

Practice I.D. Number:

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