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 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: