To take advantage of Daavlin's Free Insurance Assistance Program, please enter the information below and submit the following by fax, email, or mail to Daavlin:
  • Fax: 419-636-7916
  • Mail: PO Box 626 Bryan, OH 43506
  • Email: phototherapy@daavlin.com
  • An enlarged copy of the front and back of your insurance card
  • Your prescription (Must state which lamp type - NB UVB, BB UVB or UVA)
  • A letter or statement of medical necessity (Example)

Patient Information  
*First Name
*Last Name
*Phone
*Email
*Address
*City
*State 
 
*Zip
*Date of Birth
*Sex:
  M
*Physician Name
How did you hear about Daavlin?
*Skin Condition
Other: (Please Specify)
*Model and Lamp Quantity
 
*Lamp Type
Other: (Please Specify) 
*Control System


   
Accessories and Options  
Distance Minder $130.00
1 Series Stand $150.00
7 Series Castors $50.00
7 Series Wall Mount Kit $20.00
M Series Table $310.00
Fitover Glasses $8.50
Regular Glasses $9.50
Additional Pair of Regular Goggles $7.50 (Each unit comes with 1 pair)

Please Note:
If required by your prescription, FlexRx: Exposure Limiting Software may be added to either of these control systems.

Order Confirmation
By entering my name I hereby confirm the above order is accurate and complete to the best of my knowledge. I understand that a doctor's prescription and letter of medical necessity must accompany all orders. Daavlin will contact me with information regarding my insurance benefits before my order will be finalized.


*Name
*Date 
*Shipping Method 
 


I confirm that I have read Daavlin's HIPPA Privacy Policy (Download here) *
I confirm that I have read Daavlin's
Patient Responsibilities and Patient Bill of Rights Policy (Download Here)
*
I confirm that I have read and accept the Terms and Conditions of Sale Agreement (Download here) *
I authorize Daavlin to acquire medical benefits for Durable Medical Equipment on my behalf *

 




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