Online Home Order Form

Quick, secure, and easy — the Phothera Physician E-Form streamlines your prescribing process. Submit home phototherapy orders in just a few clicks with built-in accuracy checks and HIPAA-compliant security, helping you save time and deliver care faster.

Please note: This e-form allows support staff to draft a prescription, save it, and email it to the prescribing physician or healthcare provider for final review and signature.

To ensure HIPAA compliance, your practice must first create a Jotform account using the email address where prescriptions should be sent. Setting up an account is quick, free, and helps safeguard patient information.
Patient Information:
Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Patient or Guardian Email (To receive order updates and general device training)*
Parent/Guardian Name (If Under 18)

First NameLast Name
Patient Skin Type:
Home Phototherapy Product:
HCPCs, Product and Description:*
Other, Please Specify
Diagnosis:

ICD-10 Code Must Be Indicated (helpful tip: see our helpful ICD-10 Quick Reference Guide)
Condition or Diagnosis*
Other:
Prescription:
NBUVBOther
Zero Exposures (Patient will need a code from provider to begin treating)75 Exposures (Patient will receive code from customer care specialist)100 Exposure (Patient will receive code from customer care specialist)250 Exposures (Patient will receive code from customer care specialist)
100 ExposuresUnlimited Exposures
Treatment Mode
Dosimetry: (mJ) Patient must be able to follow instructions and enter dose manually for each treatment. Must maintain treatment records to adjust dose based on reaction and/or missed treatments.Time (mm:ss): Patient must be able to follow instructions and enter treatment time manually. Must maintain treatment records to adjust time based on reaction and/or missed treatments.
Guided Mode: (LITE Study Proven) Smart control technology delivers preprogrammed dose with real-time dosimetry light measurement, and automatically adjusts based upon user response. Guided Mode provides patient ease-of-use. – MUST PRESCRIBE VIA CLEARLINK.PHOTHERA.COM
Statement of Medical Necessity (Required for Insurance Approval):
99 Months (99 = lifetime)Other
Other:
Hands 2%Feet 2%Scalp 9%Back 18%Chest/Abdomen 18%Arms 18%Legs 18%
Total BSA:*
List Previous Treatments:
Was it Effective?
List Previous Treatments:
Was it Effective?
Has the patient been treated with UV Light Therapy in the office?*
Was it Effective?*
If necessary, please explain your answer for treating, or not treating in-office:
I.e. No in-office booth available
Is the patient/caregiver reliable, motivated, and able to adhere to instructions?*
Supportive Documents:
Coordinating Medical Records:*

Use this section to upload any chart notes that may be of value when processing the claim.
Cancelof
Patient ID Card (front & back) and/or Insurance Information:*

Patient ID Card Mandatory for Medicare
Cancelof
Provider Information
Provider's Full Name*

First NameLast Name
Provider NPI Number:*
Name of Clinic:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Email*
example@example.com
Clinic's Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Prescription Confirmation

I certify that I am the physician or healthcare provider identified on this form. I have reviewed this Written Order. Any statement on my letterhead hereto has also been reviewed and signed by me. I certify that this patient and/or caregiver is capable and will be trained on the proper use of the products prescribed on this Written Order. The patient's record contains supporting documentation that substantiates the utilization and medical necessity of the product listed, and the physician notes and other supporting documentation will be provided upon request. I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient's medical record.
Signature*

Powered by Jotform SignClear
Today's Date*

MonthDayYear
Date
Please note: This e-form allows you to draft a prescription, save it, and email it to the prescribing physician for final review and signature. To ensure HIPAA compliance, your practice must first create a Jotform account using the email address where prescriptions should be sent. Setting up an account is quick, free, and helps safeguard patient information.

Upon clicking "Send For Review and Signature", if your practice does not have an account established, you will be asked to create one.
Should be Empty:

Patient Information:

Home Phototherapy Product:

Diagnosis:

Prescription:

Treatment Mode

Statement of Medical Necessity (Required for Insurance Approval):

Supportive Documents:

Provider Information