Dermatologist Templates

In-office Phototherapy Letter

Click Here to Download the In Office Phototherapy Letter (MS Word)

In-office Excimer Letter

Click Here to Download the In Office Excimer Letter (MS Word)

Home Phototherapy Letter

Click Here to Download the Home Phototherapy Necessity Letter (MS Word)

Pre-Authorization Request Template

Click Here to Download the Preauthorization Form (MS Word)

Want to see the letter before downloading it? See a copy of the letter here.

Letter of Medical Necessity

Click Here to Download the Medical Necessity Letter (MS Word)

Want to see the letter before downloading it? See a copy of the letter here.

Phototherapy dosing instructions and tracking

Click Here to Download the UVB Dosing Chart Log and Instructions

Notice:

The information provided in the document above should only be used under the guidance of your physician/doctor/medical professional.  Use your phototherapy device as you would a prescription medication under the direction of a physician. Like any medication, phototherapy can be harmful if not used properly.

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