Evicore radiation therapy physician worksheet 2025

1. Click ‘Get Form’ to open the evicore radiation therapy physician worksheet in the editor.
2. Begin by entering the patient's name and the radiation therapy start date in the designated fields. Ensure the date is formatted as mm/dd/yyyy.
3. Select the appropriate diagnosis type from the provided options, including benign cranial and non-skin requests. If necessary, specify any other non-cranial/skin benign conditions in the space provided.
4. Outline the treatment plan by choosing either External Beam Radiation Therapy (EBRT) or Brachytherapy. If EBRT is selected, answer additional questions regarding technique and fractions.
5. For brachytherapy, indicate the dose rate and number of fractions to be delivered.
6. Finally, utilize the space at the end of the form to note any additional information relevant to the treatment plan.

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