Radiation Therapy Physician Worksheet
(As of 31 January 2017)
If the treatment is for metastases from multiple myeloma, 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.
What is the radiation therapy treatment start date (mm/dd/yyyy)?
1. Is treatment planned for palliation of multiple myeloma?
If yes is selected, skip forward to question #3.
Is treatment planned for a solitary plasmacytoma (either bone or
If treatment is not planned for palliation of multiple myeloma or for solitary plasmacytoma, please
stop and use the appropriate worksheet for the patient’s diagnosis.
What is the location/site being treated? ___________________
a. Are you treating a second and/or third site?
If no is selected, skip forward to question #5.
b. What is the second location/site being treated? ___________________
c. What is the third location/site being treated? ___________________
d. Will sites be treated concurrently? Yes No