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Insurance Form
Patient
Name:___________________________________________
Insurance Company/Plan:__________________________________
Patient I.D. Number:______________________________________
DOB:_______________
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 guidlines for management of this disorder.
Publication # and Title
AHCPR93-0551 - Depress: Guideline Vol. 2
AHCPR93-0553 - Depress: Patient Guide
__________________________________________________
Prescribing Doctor (Date)
__________________________________________________
(Practice l.D. Number)
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