While we do not make any medical or health claims for our lights, research shows that light does influence us. You doctor may want to prescribe a light therapy device for you if you have Seasonal Affective Disorder (SAD) or depressive/anxiety conditions. Your insurance company may or may not cover it for you. It depends on your particular policy. If you wish, you may print out the following claim form to take it to your health care provider.
Justification of Purchase of Durable Medical Equipment |
| Claimant: ______________________________________ SSN: ____________________ |
| Insured: ______________________________________ Phone: ____________________ |
| Address: _________________________________________________________________ |
| City: _________________________ Province: ________ Postal code: ____________ |
| Insurer: _________________________________________________________________ |
Policy #: _________________ Group # __________________
|
| Medical Device: THERAPEUTIC LIGHT DEVICE - HCPC Code E-1399 (Miscellaneous) |
| ______ Bright Light Therapy Device |
______ Full Spectrum Light Therapy Device
|
| Diagnosis: |
| ______ DSM IV 296.90 Mood Disorder, NOS (not otherwise specified) with seasonal |
| pattern specifier. Essential feature is the onset and remission of major depressive |
| episodes at characteristic times of the year. Used for Seasonal Affective Disorder. (SAD) |
| ______ DSM IV 296.3x Major Depression, Recurrent |
| ______ DSM IV 296.4x Bipolar Disorder, Manic (Use full spectrum with manic individuals) |
| ______ DSM IV 296.5x Bipolar Disorder, Depressed |
| ______ DSM IV 296.6x Bipolar Disorder, Mixed (Use full spectrum with manic individuals) |
| ______ DSM IV 296.7x Bipolar Affective Disorder Unspecified |
| ______ DSM IV 296.80 Bipolar Disorder, NOS (not otherwise specified) |
| ______ DSM IV 296.89 Bipolar II |
| ______ DSM IV 300.21 Agoraphobia Used for housebound individuals. |
| ______ DSM IV 311.00 Depressive Disorder, NOS (not otherwise specified) |
| ______ DSM IV 314.00 ADD and ADHD, Predominantly Inattentive without hyperactivity |
| ______ DSM IV 314.01 ADD and ADHD, Combined with hyperactivity |
______ _____________ __________________________________________________________
|
| Physician: __________________________________________ License #: _________________ |
| Address: __________________________________________ Office Phone: ______________ |
| City: ________________________ Province: ________ Postal code: __________________ |
Signature: __________________________________________ Date: __________________
|
|
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|
| I certify that the above is correct and true to the best of my knowledge. |
| I request that benefits be directly paid to the claimant or the insured |
| Claimant Signature: ______________________________________ Date: ________________ |
Signature of Insured: ______________________________________ Date: ________________
|
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CLAIMANT: Please have your physician fill out the top portion first, then complete the bottom portion and mail to your insurer with a copy of the sales receipt/invoice. |
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