Get the free MRI Requisition Form - brighamandwomens

MRI REQUISITION ORDERING PROVIDER INFORMATION Ordering Provider NPI Radiology Scheduling Telephone: 617 732 – 6248 Toll Free: 866 – 345 — RAY Hours : 8:00am 5:00pm, Monday – Friday Ordering

How to fill out mri requisition form

How to fill out an MRI requisition form:

1. Start by obtaining the form: The MRI requisition form can typically be obtained from your healthcare provider or the imaging center where you will be undergoing the MRI scan.
2. Personal information: Begin by filling out your personal information section on the form. This will usually include your full name, date of birth, address, and contact information. Double-check for accuracy to ensure that there are no mistakes.
3. Referring physician information: Include the details of the physician or healthcare professional who is referring you for the MRI scan. This will typically include their name, contact information, and any relevant identification numbers.
4. Insurance information: Fill in the necessary insurance information, including your insurance provider's name, policy number, and group number. This section is crucial for billing purposes and to ensure that your insurance coverage is properly applied.
5. Medical history: Provide a comprehensive medical history, including any existing health conditions, previous surgeries, current medications, and allergies. It's important to provide accurate and detailed information here, as it can assist the radiologist in interpreting the results more effectively.
6. Reason for the MRI: Indicate the specific reason or symptoms that have led to the need for an MRI. This can include a description of your symptoms, the location of the issue, and any relevant information recommended by your healthcare provider. The more detailed and specific you can be, the better it will help the radiologist analyze the images.
7. Additional instructions: If your healthcare provider has given you any additional instructions regarding the MRI, such as fasting requirements or the need to discontinue certain medications, make sure to note them on the form.

Who needs an MRI requisition form?

1. Patients: Individuals who have been advised by their healthcare provider to undergo an MRI scan for diagnostic purposes will require an MRI requisition form. This includes patients with suspected or diagnosed medical conditions that may require further evaluation through imaging.
2. Referring healthcare professionals: Physicians, specialists, or other healthcare professionals who have identified the need for an MRI as part of their patient's diagnostic journey will need to complete and sign the MRI requisition form. They provide crucial information about the specific area or aspect to be examined during the MRI.
3. Imaging centers or facilities: The staff at the imaging center or facility where the MRI will take place also need the MRI requisition form. This form helps them verify the essential details regarding the patient, the referring physician, and the requested procedure. It ensures that the MRI can be scheduled and performed correctly, as well as aids in the billing and reporting processes.

Remember, it is vital to consult with your healthcare provider for personalized guidance and specifics on filling out the MRI requisition form, as requirements may vary depending on the medical institution and the specific circumstances of the scan.

For pdfFiller’s FAQs

What is mri requisition form?

The MRI requisition form is a document that is used to request an MRI (magnetic resonance imaging) scan. It provides information about the patient, the reason for the scan, and any specific instructions for the procedure.

Who is required to file mri requisition form?

Medical professionals, such as doctors or healthcare providers, are required to fill out the MRI requisition form for their patients. This ensures that the necessary information is provided for the scan to be performed accurately and safely.

How to fill out mri requisition form?

To fill out the MRI requisition form, medical professionals typically need to provide information about the patient, including their name, date of birth, and relevant medical history. They also need to indicate the reason for the MRI scan and any specific instructions for the procedure. The form may also require the provider's contact information and signature.

What is the purpose of mri requisition form?

The purpose of the MRI requisition form is to provide a formal request for an MRI scan. It helps ensure that the scan is performed for valid medical reasons and provides all the necessary information to guide the scan, interpret the results, and ensure patient safety during the procedure.

What information must be reported on mri requisition form?

The MRI requisition form typically requires information such as the patient's name, date of birth, contact information, relevant medical history, reason for the MRI scan, any specific instructions for the procedure, and the provider's contact information and signature.

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