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 circle the location the patient prefers to be seen, and fax this completed form to the provided fax number:
Fort Payne, AL - 256-997-9208
Gadsden, AL - 256-547-8703
Anniston, AL - 256-847-3469
Montgomery, AL - 334-273-9733
Sylacauga, AL - 256-245-0624
Selma, AL - 833-292-6780
Winfield, AL - 205-707-1179
Demopolis, AL - 334-460-0039
Tuscaloosa, AL - 205-245-8209
Digital Signature of Referring Physician
Should be Empty: