Get Mri Requisition Form - Brighamandwomens

The MRI Requisition Form is an essential document for ordering magnetic resonance imaging services. This guide will walk you through each section of the form to ensure accurate and efficient completion.

Follow the steps to correctly fill out the MRI requisition form.

1. Click ‘Get Form’ button to obtain the MRI requisition form and open it in the editor.
2. In the 'Ordering Provider Information' section, fill in the name of the ordering provider and their National Provider Identifier (NPI). Ensure to include the provider’s contact phone number and fax number as well as the ordering site.
3. In the 'Patient Information' section, accurately enter the patient's name, date of birth, address, telephone number, city, state, and zip code. If available, include the patient's work or cell phone number.
4. Under 'Does your patient have the following?', check off any applicable conditions or implants that the patient may have, such as a pacemaker or history of claustrophobia. If your patient requires sedation, note that it must be prescribed by the ordering provider.
5. In the 'Laboratory Results and Allergies' section, specify any known allergies, particularly to contrast material, and provide relevant laboratory results, including BUN and creatinine levels along with any diabetes status.
6. For 'Exam Selection', select and specify the necessary examinations, such as brain or knee MRI, ensuring to indicate left or right side as appropriate.
7. Complete the 'Primary Diagnosis' and 'Relevant History' sections to outline the medical reason for the MRI.
8. Lastly, in the 'Insurance Information' section, list the insurance carrier and authorization number. Don't forget to include the policy number.
9. Obtain the physician’s signature and date to finalize the requisition form.
10. Once all sections are filled out, you can save your changes, download, print, or share the completed MRI requisition form.

Complete your MRI requisition forms online today for a smoother process.