Fillable Liver Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

Fill Online, Printable, Fillable, Blank Liver Cancer Radiation Therapy Physician Worksheet (As of (eviCore) Form

Use Fill to complete blank online EVICORE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Liver Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

On average this form takes 9 minutes to complete

The Liver Cancer Radiation Therapy Physician Worksheet (As of (eviCore) form is 2 pages long and contains:

  • 0 signatures
  • 39 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your eviCore forms online.

BROWSE EVICORE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Liver Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of liver cancer. If the treatment is for metastases from liver
cancer, 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 treatment start date (mm/dd/yyyy)?
_____ /_____ /______
1.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
2.
What is the treatment intent?
Palliative
Definitive
Post-operative (adjuvant)
Pre-operative (neo-adjuvant)
3.
If post-operative is the treatment intent, then answer the following questions:
a. What is the clinical T stage?
T0
T1
T2
T3
T4
Tis
b. What is the nodal status?
N0
N1
N2
c. What is the resection margin status?
Negative margins
Positive margins
N/A
4.
What technique will be used to deliver the radiation therapy?
External beam radiation therapy (EBRT)
Brachytherapy
Selective internal radiation therapy (SIRT)
Continued on next page
Liver Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
5.
If EBRT is the selected treatment, then answer the following questions:
a. What EBRT technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase I Phase II
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Number of fractions: ______ Number of fractions: ______
b. If a form of IMRT was selected, was 3D conformal technique considered? Yes No
c. Will daily image-guided radiation therapy (IGRT) be used? Yes No
6.
If brachytherapy is the selected treatment, then answer the following questions:
a. What is the dose rate?
Low Dose Rate High Dose Rate
b. How many applications will be used?
Applications: ________
7.
If SIRT is the selected treatment plan, how many treatments will be
utilized?
Treatments: __________
8. Will the patient receive concurrent chemotherapy?
Yes No
9.
Note any additional information in the space below. If SIRT or other brachytherapy technique will be
used, provide details and rationale for selection of the SIRT or brachytherapy.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Liver Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document