Follow the steps to fill out the form online.

1. Click the ‘Get Form’ button to access the EviCore Oncology CT - MR Fax Form and open it for editing.
2. Provide the ordering provider's information, including their first name, middle initial, date of birth (in mm/dd/yyyy format), gender, street address, apartment number (if applicable), city, state, and zip code. Additionally, input their home phone, cell phone, primary contact name, health plan, member ID, and group ID.
3. Fill in the physician's details, including their first name, last name, primary specialty, TIN, phone number, NPI, fax number, address, suite number, city, state, zip code, office contact name, extension, and contact email.
4. Next, enter the facility or site information, including the group/site name, primary specialty, TIN, NPI, site fax, address, suite number, city, state, and zip code.
5. Indicate the procedure by selecting the appropriate radio button for oncology imaging. Provide a diagnosis, including applicable CPT codes and ICD-10 codes, as well as the date of the last visit.
6. Address clinical information, including questions about the cancer diagnosis, biopsy confirmation, tumor size, metastatic disease, and chemotherapy history. Complete the required checkboxes and enter specific information as applicable.
7. In the final section, indicate who is making the request by selecting either the ordering physician, facility, or other options. Print your name and title, then provide your signature and the date.
8. Once all sections are completed, review the form for accuracy. You may then save your changes, download the completed document, print it if necessary, or share the form with the relevant parties.

Begin completing your documents online today for a more streamlined approach.