Edit, Download, and Sign the Home Phototherapy Order Packet and Instructions
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Filling out this form is straightforward. Begin by completing the necessary patient information fields. Ensure that all required fields are filled out accurately.
How to fill out the Home Phototherapy Order Packet and Instructions?
1
Complete the patient information section.
2
Fill in the insurance information if applicable.
3
Select the desired product and any optional upgrades.
4
Sign and date the form.
5
Submit the completed form via fax, mail, email, or online.
Who needs the Home Phototherapy Order Packet and Instructions?
1
Patients who require home phototherapy devices for treatment.
2
Prescribers who need to provide a written order for their patients.
3
Insurance companies verifying patient eligibility and benefits.
4
Medical device distributors processing the order and delivery.
5
Healthcare providers managing patient treatment plans.
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1
Open the PDF file on PrintFriendly.
2
Click on the 'Edit' button to enter editing mode.
3
Fill in the required form fields and make any necessary changes.
4
Add text, annotations, and signatures as needed.
5
Save the edited PDF for submission.
What are the instructions for submitting this form?
To submit this form, you can fax it to 419-636-7916 or 419-636-1739, mail it to Daavlin, PO Box 626, Bryan, OH 43506, or email it to phototherapy@daavlin.com. You can also use the online patient order form available at www.daavlin.com. Ensure all required sections of the form are accurately completed and include the physician's written order and relevant chart notes if using insurance. My advice is to double-check all information before submission to avoid any delays in processing.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates listed for this form for 2024 and 2025. The form can be used whenever a patient needs to order a home phototherapy device.
What is the purpose of this form?
The purpose of this form is to facilitate the ordering process for Daavlin's home phototherapy devices. It collects essential patient and insurance information required for order processing and insurance verification. Additionally, it ensures that all necessary prescriptions and chart notes are included to expedite the approval and delivery process.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Info: Includes fields for patient name, address, phone number, date of birth, gender, and email consent.
- 2. Insurance Info: Requires primary and secondary insurance details, policy holder information, and authorization for insurance verification.
- 3. Purchase Info: Options for purchasing with or without insurance, including payment methods and Daavlin payment plan.
- 4. Product Selection: Choose the desired phototherapy unit and any optional upgrades or accessories.
- 5. Signatures: Patient or guardian signature required to confirm the accuracy of information and consent to terms.
What happens if I fail to submit this form?
Failure to submit this form can delay the processing and delivery of your phototherapy device. Insurance verification and approval would also be hindered.
- Delayed Treatment: Without the device, the patient’s treatment may be delayed.
- Insurance Issues: Failure to verify insurance may result in out-of-pocket expenses.
- Incomplete Orders: Orders cannot be processed without complete and accurate information.
How do I know when to use this form?
- 1. New Phototherapy Device: For ordering a new home phototherapy device.
- 2. Upgrade Existing Device: When upgrading your existing device with additional features or accessories.
- 3. Insurance Verification: To verify insurance eligibility and benefits for the device.
- 4. Prescription Requirement: When a prescription from a licensed physician is needed to order the device.
- 5. Patient Information Update: Updating patient information required for processing the order.
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What are the steps to fill out the form?
Complete the patient information, fill in insurance details, select the product, sign and date the form, and submit it.
Can I submit the form online?
Yes, you can submit the completed form online via Daavlin's patient order form portal.
Is there a charge for shipping?
Shipping within the contiguous 48 states is included in the price of the unit. Additional charges apply for delivery to Alaska, Hawaii, or special delivery requirements.
What if I need help with the form?
Contact Daavlin's representatives at 1-800-322-8546 for assistance with the form.
Are there optional upgrades available?
Yes, optional upgrades and accessories for the phototherapy units are available but may not be covered by insurance.
How do I know if my insurance will cover the device?
Complete the insurance information section and Daavlin will verify your insurance benefits and contact you with details.
What do I need to include with my form submission?
Include the completed patient order form, physician's written order, and relevant chart notes if using insurance.
