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For Prescribing Physicians
Prescribe at-home
UVB phototherapy
for your patients
Zerigo Health's FDA-cleared narrowband UVB system delivers AAD-validated phototherapy in your patient's home — with built-in dosing protocols and dedicated Care Guide support.
Psoriasis Eczema Vitiligo Seborrheic Dermatitis Leukoderma
Prescription Form
Zerigo Health Rx Form 2026
Form 40-0124 Rev. K · 3 pages · Fillable PDF
- ✓ Electronic signatures accepted
- ✓ No printing or scanning required
- ✓ AAD dosing reference on pages 2–3
- ✓ Standard prescription: 24 months
Zerigo_Health_Rx_Form_2026.pdf
73%
Treatment adherence
Among engaged Zerigo members
5
FDA-cleared indications
All skin types I–VI
24 mo
Standard prescription
Duration per written order
AAD
Protocols built in
Dosing applied automatically by device
How to complete the form
Six steps to prescribe Zerigo for your patient
Download the prescription form above, then complete each section before submitting by email or fax.
1
Complete patient information
Full name, date of birth, address, phone, and email. If the patient is a minor, include a parent or guardian name.
2
Select one diagnosis code
Choose a single ICD-10 code. Eczema codes begin with L20.x; psoriasis codes begin with L40.x.
One code only3
Select Fitzpatrick skin type (I–VI)
This determines the AAD dosing protocol applied automatically by the device. Reference tables are included on pages 2–3 of the form.
4
Complete the statement of medical necessity
Indicate symptom severity (mild / moderate / severe), body surface area (% BSA), and affected body locations. Include PASI or EASI scores if available.
5
Enter your prescriber information
Name, medical license number, NPI number, practice address, phone, fax, and email.
6
Sign and submit
Apply your electronic signature in the PDF. Submit by email or fax using the contact details in the section below.
No printing requiredPhysician responsibility
Zerigo Care Guides and the Zerigo device do not furnish medical advice or make medical decisions. As the prescribing physician, you remain responsible for all treatment decisions, including any determination to suspend or discontinue the prescription.
Submit completed forms
Three ways to send us the prescription
Fax
(844) 562-6896Available 24/7
About Zerigo Health
About Zerigo Health
FDA-cleared1
Cleared for psoriasis, eczema, vitiligo, seborrheic dermatitis, and leukoderma across all skin types (I–VI).
AAD protocols built in2
The device automatically applies AAD dosing guidelines based on the Fitzpatrick skin type selected at prescription.
Zerigo Care Guides3
Dedicated Care Guides support your patients through onboarding, adherence, and ongoing treatment — not medical decisions.
73% adherence rate4
Among engaged Zerigo members — supported by remote monitoring and proactive Care Guide outreach.
1 Clarify Medical Phototherapy System 510(K); Form FDA 3881 (8/14)
2 AAD = American Academy of Dermatology. Narrowband UVB phototherapy is recommended by the AAD for the treatment of psoriasis and eczema.
3 ZerigoCare™ licensed team includes licensed clinicians and/or supervised licensed healthcare professionals. Program is supervised and personalized. ZerigoCare™ is a trademark of Zerigo Health.
4 Gelfand JM, Armstrong AW, et al. Home- vs Office-Based Narrowband UV-B Phototherapy for Patients With Psoriasis. JAMA Dermatol. 2024;160(12):1320-1328. doi:10.1001/jamadermatol.2024.3897 "Adherence on Zerigo vs Others." Zerigo Health Real-World Evidence Deck. March 2025; Slide 9. (Primary sources: PMC8953825; Apremilast Adherence and Persistence Study.)