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 Name
Last Name
Patient's Phone Number
Please enter a valid phone number.
DOB
-
Month
-
Day
Year
Date
Referring Physician's Full Name
First Name
Last Name
Referring Physician's Email Address
example@example.com
Referring Physician's Phone Number
Please enter a valid phone number.
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 analgesics
Injections (e.g., corticosteroids, hyaluronic acid)
Physical Therapy
Weight loss/lifestyle modification
Bracing 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 narrowing
Grade 3 -Multiple osteophytes, definite JSN, sclerosis, possible bony deformity
Grade 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 select which location for which the patient should receive treatment:
Fort Payne, AL
Gadsden, AL
Anniston, AL
Montgomery, AL
Sylacauga, AL
Winfield, AL
Demopolis, AL
Digital Signature of Referring Physician
Should be Empty: