Get Evicore Radiation Therapy Worksheet

The Evicore Radiation Therapy Worksheet is an essential document for initiating radiation therapy for breast cancer. This guide will help you navigate through the form step-by-step, ensuring that you provide all necessary information correctly.

Follow the steps to complete the Evicore Radiation Therapy Worksheet effectively.

1. To begin, click the ‘Get Form’ button to obtain the worksheet and open it in your preferred editor.
2. Enter the patient's name in the designated field at the top of the form. This identification is crucial for the processing of the worksheet.
3. Provide the radiation therapy treatment start date in the format (mm/dd/yyyy) in the specified field.
4. Indicate whether the treatment is directed to the primary site (i.e., the breast) by selecting 'Yes' or 'No' in the corresponding box.
5. If treatment is not directed to the primary site, ensure to submit a request for the relevant metastatic site.
6. Indicate if the patient has distant metastatic disease, marking 'Yes' or 'No' as appropriate.
7. Specify if you will be delivering adjuvant therapy to the whole breast or chest wall using two gantry angles and 3D conformal treatment planning by selecting the corresponding option.
8. If applicable, indicate the direction of treatment by selecting 'Right breast,' 'Left breast,' or 'Bilateral breast' in the provided options.
9. Fill in the T-stage by selecting the correct option that reflects the patient's pathologic T-stage.
10. Define the treatment plan for the initial phase by choosing from options like 'Whole breast radiotherapy,' 'Partial breast radiotherapy,' or others provided.
11. State whether the treatment will include internal mammary nodes by selecting 'Yes' or 'No.'
12. Select the treatment technique for the initial phase of treatment from the various methods listed, such as 'Intensity modulated radiation therapy (IMRT)' or '3D conformal.'
13. For the boost phase technique, select the appropriate methods provided, including 'Photons' or 'No boost phase will be delivered.'
14. Note additional information if required in the space provided at the end of the form, ensuring clarity and completeness.
15. Upon completion, users can save any changes made, download, print, or share the worksheet as necessary.

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