Workers’ Compensation MRI Authorization Request Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Contact Method

Employer Name

Workers’ Compensation Insurer/Administrator Name

Claim Number

Date of Injury

Date

Claim Adjuster/Contact Name

First NameMiddle NameLast Name

Claim Adjuster/Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Claim Adjuster/Contact Email

example@example.com

Brief Injury Description

Date Symptoms Began

Date

Is the Injury Work-Related?

Referring Provider / Clinic Name

Provider Phone

Please enter a valid phone number.Format: (000) 000-0000.

Provider Fax or Email

Relevant Clinical Notes Supporting MRI Request

Requested MRI Body Area

Laterality

Preferred Imaging Facility

Urgency Level

Preferred Appointment Date

Date

Hour MinutesAM/PM Option

Transportation or Accessibility Needs

Scheduling Restrictions

Signature