Get Requisition For Medical Imaging, Form 83d56. Please Complete In Ink And Fax Copy Of Report To

This guide provides clear instructions on completing the Requisition For Medical Imaging, Form 83D56. Properly filling out this form is essential for facilitating medical imaging requests efficiently.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to access the Requisition For Medical Imaging, Form 83D56.
2. Fill in the worker information section, including the worker's last name, first name, middle initial, gender, WorkSafeBC claim number, address, personal health number (CareCard), and phone numbers (home, work, and cell). Be sure to include area codes.
3. Indicate the date of birth and date of injury in the specified format (yyyy-mm-dd).
4. Select whether a translator is required. If yes, tick the corresponding box.
5. Provide details on the examination required and any relevant prior imaging, including the location and date(s) of prior imaging.
6. State if the patient is taking anticoagulants and provide the patient's weight in kilograms.
7. Document the diagnosis or medical history, along with any essential medical information, including if the patient is pregnant and if they have any allergies or asthma.
8. Confirm normal renal function and provide details if recent eGFR/Creatinine tests were required.
9. Determine if the patient is claustrophobic and, if applicable, indicate the need for medication or an open MRI.
10. Include a history of welding, grinding, or metal work, and surgically implanted devices. Provide details and any necessary reports.
11. Fill out the ordering physician's information, including name, phone number, fax number, and MSP number. Ensure the signature is included.
12. Indicate where copies of the report should be sent by providing fax numbers and the appropriate recipients (including WorkSafeBC).
13. Review the form for completeness and accuracy. Once verified, you can save changes, download, print, or share the completed form.

Complete your Requisition For Medical Imaging, Form 83D56 online today to ensure timely processing.