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.

If this is your first time using this form, please review the instructions in the dropdown menu below.

Attention: If submitting multiple prescriptions, do not use your browser's back button to return to a blank form, as this will override your previous submission – begin a new prescription from the Phothera page

This form is for home phototherapy prescriptions only
- This form can be completed and signed in one sitting. If you would like to save and sign later, follow these steps:
  
  Step 1: Create a Jotform Account
  
  To protect patient information and ensure HIPAA compliance, your practice must first create a free Jotform account.
  - Upon signup, use the email address where completed prescriptions should be sent.
  - Account setup is quick and required before using the form.
  Step 2: Complete the Prescription Draft
  Once logged in, fill out the online form with the required patient and treatment information.
  - Support staff may complete this step on the provider's behalf.
  - Forms can be saved and returned to later if needed.
  Step 3: Send to the Prescribing Provider
  After completing the form, click 'submit and review' to send the completed prescription to the account email (step 1) for review.
  
  Step 4: Provider Review & Signature
  The provider reviews the prescription, makes any necessary changes, and signs to finalize the order
  
  Attention: If submitting multiple prescriptions, do not use your browser's back button when creating a new prescription, as this will override your previous submission. Begin a new prescription from the Phothera prescribing page or a saved link to this order form.
- 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.
- Email (for training and general correspondence purposes)
- Parent/Guardian Name (If Under 18)
  
  First NameLast Name
- Diagnosis:
- ICD-10 Code Must Be Indicated (helpful tip: see our helpful ICD-10 Quick Reference Guide HERE)
- Condition or Diagnosis*
- Psoriasis Diagnosis Code:*
- Atopic Dermatitis Diagnosis Code:
- Vitiligo Diagnosis Code:
- Seasonal Affective Disorder:
- Hyperhidrosis:
- Other Diagnosis, Enter Here:*
- I and II (200 mJ) – vitiligo patients, or, if unsure, this is a safe selection for all patientsIII and IV (400 mJ)V and VI (600 mJ)
- Home Phototherapy Product:
- HCPCS, Product, and Description (Most Popular Choices for Insurance Coverage)**
- Other Photherapy Product Selection:
- SAD & Hyperhidrosis Product Selection:
- Prescription:
- Prescribed Lamp Type:
- Other Lamp Type:
- Treatment Mode
- Unlimited Exposures (Default: Requires no additional support from provider)100 Exposures (Requires provider to provide a refill code to patient when all exposures have been used)
- Guided Mode: Safest and Easiest mode for patients. Utilized in a randomized clinical trial (LITE Study) published in JAMA demonstrating enhanced patient adherence rates and safety outcomes. Clearlink Touchscreen Controller guides the patient through every treatment. Standard AAD recommended protocol available below.Dosimetry: (mJ) The Patient must be able to follow instructions and enter the dose manually for each treatment. The patient must maintain treatment records to adjust their dose based on their reaction and/or missed treatments.Time: (mm:ss)The Patient must be able to follow instructions and enter the time manually for each treatment. The patient must maintain treatment records to adjust their treatment time based on their reaction and/or missed treatments.
- Dosimetry: (mJ) The Patient must be able to follow instructions and enter the dose manually for each treatment. The patient must maintain treatment records to adjust their dose based on their reaction and/or missed treatments.Time: (mm:ss)The Patient must be able to follow instructions and enter the time manually for each treatment. The patient must maintain treatment records to adjust their treatment time based on their 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.
- Statement of Medical Necessity (Required for Insurance Approval):
- YesNo
- 99 Months (99 = lifetime)Other
- YesNo
- Hands 2%Face 3%Feet 2%Scalp 9%Back 18%Chest/Abdomen 18%Arms 18%Legs 18%
- Total BSA:*
- Please Select A Severity Rating:
- List Previous Treatments:
- Was it Effective?
- Date Treatment Began
  
  MonthDayYear
  Date
- Has the patient been treated with UV Light Therapy in the office?*
- Did the patient's condition improve from in-office phototherapy?*
- How many months of in-office UV Light there were administered?
  A select few insurance companies may require patients to complete three months of in-office treatment.
- Therapy is considered long-termIn-office phototherapy is not available to the patientDistance and travel time to the officeCo-pay cost of frequent in-office visitsUnable to take time away from work or schoolOther
- If choosing "other", please explain:
  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's 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 identified on this form. I have reviewed this Physician's 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.

Attention: If submitting multiple prescriptions, do not use your browser's back button, as this will override your previous submission – begin a new prescription from the Phothera page
FRM-00184[0]
Should be Empty:

Patient Information:

Diagnosis:

Home Phototherapy Product:

Prescription:

Treatment Mode

Statement of Medical Necessity (Required for Insurance Approval):

Supportive Documents:

Provider Information