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

Fill Online, Printable, Fillable, Blank Vulva 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.

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

On average this form takes 9 minutes to complete

The Vulva Cancer Radiation Therapy Physician Worksheet (As of (eviCore) form is 3 pages long and contains:

  • 0 signatures
  • 54 check-boxes
  • 12 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
 
Vulva Cancer
Radiation Therapy Physician Worksheet
(As of 17 July 2016)
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.
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)?
_____ /______ /______
1.
Is this treatment being directed to the primary site?
Yes No
If treatment is not being directed to the primary site, submit a request for the metastatic site.
2.
Does the patient have distant metastatic disease?
Yes No
3.
a. What is the treatment intent?
Postoperative
Preoperative
Definitive (no surgery planned)
Locoregional recurrence at primary site or regional lymph nodes
Palliative (for relief of symptoms)
b. If preoperative or postoperative is the treatment intent, are any of the
following risk factors present?
Yes No
1. Tumor > 4 cm
2. > 1 mm invasion
3. Lymphovascular invasion
4. Positive Pelvic Nodes
5. Positive Inguinal/Femoral Nodes
6. Positive/Close Surgical Margin (< 8 mm)
7. Pattern of invasion (spray, diffuse)
6. Positive inguinal/femoral nodes
c. If definitive is the treatment intent, what is the patient’s initial TNM (AJCC 7
th
Edition) Stage?
Stage 0
Stage II
Stage IVA
Stage IIIA
Stage IVB
Stage I A
Stage IIIB
Stage IB
Stage IIIC
Continued on next page
Vulva Cancer
Radiation Therapy Physician Worksheet
(As of 17 July 2016)
6.
What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
EBRT and Brachytherapy
7.
If brachytherapy is included in the treatment plan, then answer the following set of questions:
a. What is the dose rate?
Low dose rate (LDR)
High dose rate (HDR)
b. How many fractions will be rendered?
Fractions: _____
c. What is the implant type?
Interstitial
Other (fill in): ________________________
8.
If EBRT is included in the treatment plan, then answer the following questions:
a. What is the treatment technique?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1
Phase 2
Phase 3
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Fractions: ______________
Fractions: ______________
Fractions: ______________
9.
Will the patient be receiving concurrent chemotherapy?
Yes No
10.
Will IGRT be used?
Yes No
Continued on next page
Vulva Cancer
Radiation Therapy Physician Worksheet
(As of 17 July 2016)
11.
Note any additional information in the space below:
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

Vulva 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