Cytokind – Physician Order Form

Cytokind – Physician Order Form

Cytokind’s E-Form provides HIPAA-compliant way to prescribe home phototherapy with a simple online submission. This form streamlines the process while ensuring accuracy and efficiency for both providers and patients. All fields marked with * are required and must be filled.
Patient Information
Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email for training and general correspondence
example@example.com
Parent/Guardian Name If Under 18

First NameLast Name
Will this prescription be processed through the patient's insurance?
Insurance Card

Please submit a photo of the front of your insurance card (and the back, if applicable)
Patient ID Card Front and Back and/or Insurance Information

Cancelof
Supportive Documents

Please attach clinical notes, chart notes, or medical records documenting medical necessity (e.g., affected Body Surface Area, diagnosis details, and past failed conservative treatments such as topical therapies). Fax Number is available upon request via email.
Coordinating Medical Records

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Provider Information
Provider's Full Name

First NameLast Name
Provider NPI Number
Name of Clinic
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Provider's Email
example@example.com
Clinic's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Device Type
Device Type
Diagnosis:
ICD-10 Code Must Be Indicated (helpful tip: see our helpful ICD-10 Quick Reference Guide HERE)
Condition or Diagnosis
Statement of Medical Necessity Required for Insurance Approval
Estimated Duration of Need

Other
Is the condition chronic?
BSA Body Surface Area and Severity Calculator
Total BSA
Please Select A Severity Rating
List Previous Treatments
Was it Effective?
Date Treatment Began

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 were administered?
Reasons for home use PLEASE CHECK ALL THAT APPLY

Other
If choosing other please explain
Is the patient/caregiver reliable motivated and able to adhere to instructions?
Prescription Confirmation
Certification Statement
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Cytokind – Physician Order Form

Patient Information

Insurance Card

Supportive Documents

Provider Information

Device Type

Diagnosis:

Statement of Medical Necessity Required for Insurance Approval

Prescription Confirmation