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Request For Personalized Coding & Reimbursement Customer Service and Support

Please fill out and submit the form below:
Within 24 hours you will be contacted by a member of the DUSA Customer Service and Reimbursement & Coding Support Team.

Nature of Request
(Please check the box which best describes the nature of your request.)

	Need information regarding which CPT procedure and office visit (E&M) codes, ICD-9 codes, and HCPCS codes to use in filing an insurance claim for a Levulan® PDT procedure.
	Need information to submit for/appeal Medicare coverage/payment of the PDT procedure and to submit for/appeal Medicare coverage/payment of the drug Levulan®.
	Need information to submit for/appeal private insurance coverage/payment of the PDT procedure and to submit for/appeal private insurance coverage/payment of the drug Levulan®.
	If there is any additional pertinent information surrounding the request, please enter it here:

Customer Information (All fields marked with * are required.)
Customer Name:*
Contact Person:*
Title:*
Mailing Address:*
City:*
State:*
Zip Code:*
E-mail:*
Phone:*
Fax:*

You may (alternatively) print off, fill in, and fax this form to:

ATTN:	Customer Service
FAX:	978.657.6502
SUBJECT:	Individual Customer Request for Coding & Reimbursement Support.

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