Hodgkins Lymphoma
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
This worksheet is to be used for curative or palliative treatment of Hodgkin’s Lymphoma. If the treatment is for
metastases from Hodgkin’s Lymphoma, please use the appropriate metastatic worksheet.
For NON-URGENT requests, please complete this document for authorization along with any relevant clinical
documentation requested within this document (i.e. radiation therapy consultation, comparison plan, etc.) before
submitting the case by web, phone, or fax. Failure to provide all relevant information may delay the determination. Phone
and fax numbers can be found on eviCore.com under the Guidelines and Fax Forms section. You may also log into the
provider portal located on the site to submit an authorization request. URGENT (same day) requests must be submitted
by phone.
First Name:
Middle Initial:
Last Name:
DOB (mm/dd/yyyy):
Member ID:
What is the radiation therapy start date (mm/dd/yyyy)?
1. What is the histology?
Nodular Lymphocyte Predominant Hodgkin’s Disease (NLPHD)
Classic Hodgkin’s Disease
2.
What is the treatment intent?
Adjuvant (i.e. following chemotherapy)
Definitive
Salvage (Curative)
Palliative
3.
If Adjuvant is the selected treatment intent, then please answer the following questions:
a. What was the chemotherapy regimen?
ABVD
Stanford V
BEACOPP
b. How many cycles were given?
Cycles: ______
c. What is the response to chemotherapy?
No response
Partial response
4. What is the stage at diagnosis?
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IVA
Stage IVB
