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Get NIA Head and Neck Cancer Relation Therapy Treatment Plan Checklist 2015-2021

A medical necessity review. The most efficient way to submit a review request is via www.RadMD.com or call the NIA Call Center toll free number. Please do not fax the checklist to NIA. General Information Patient Name : Radiation Oncologist : Radiation Therapy Facility : Treatment Planning Start Date (i.e. Initial Simulation): DOB: Breast Surgeon : Health Plan ID : Anticipated Treatment Start Date: Patient Clinical Information  Primary tumor site being treated: T Stage: TX T0 Tis T1 T.

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