Light Boxes, SAD Light, SAD Light Boxes

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)