Low Dose Radiation Therapy for Osteoarthritis/Pain Management Referral and Assessment Form

Low Dose Radiation Therapy for Osteoarthritis/Pain Management Referral and Assessment Form

This form is designed for referring physicians to request radiation therapy treatments for osteoarthritis/pain management.
Patient's Name

First NameLast Name
Patient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DOB

MonthDayYear
Date
Referring Physician's Full Name

First NameLast Name
Referring Physician's Email Address
example@example.com
Referring Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Primary Insurance Carrier
Patient's Primary Insurance Policy Number
Patient's Secondary Insurance Carrier
Patient's Secondary Insurance Policy Number
Diagnosis Code*
Location of joint to be treated*
History of Treatment (please check all that apply)

NSAIDs or other analgesicsInjections (e.g., corticosteroids, hyaluronic acid)Physical TherapyWeight loss/lifestyle modificationBracing or assistive devices
History of Symptoms to Include Pain Severity and Functional Limitation, as well as Duration.
Kellgren-Lawrence Grade

Grade 1 - Possible osteophyte formation; no definite joint space narrowing (JSN)Grade 2 - Definite osteophytes; possible joint space narrowingGrade 3 -Multiple osteophytes, definite JSN, sclerosis, possible bony deformityGrade 4 - Large osteophytes, marked joint space narrowing, severe sclerosis, and definite bony deformity
To Help Determine Medical Necessity please email the following to intake@alcancercare.com:
- Most Recent H&P
- Most Recent Progress Note
- Outside Path Report
- Earlier Radiology Reports
- Patient Demographics
- Most Recent Labs
Please circle the location the patient prefers to be seen, and fax this completed form to the provided fax number:

Fort Payne, AL - 256-997-9208Gadsden, AL - 256-547-8703Anniston, AL - 256-847-3469Montgomery, AL - 334-273-9733Sylacauga, AL - 256-245-0624Selma, AL - 833-292-6780Winfield, AL - 205-707-1179Demopolis, AL - 334-460-0039Tuscaloosa, AL - 205-245-8209
Digital Signature of Referring Physician
Should be Empty: