Procedure that requires prior approval Application form: - MRI Scanning Open / Standing / Annual – Name of Referring Clinician GP Name and Surgery Patient NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you Yes No raising this request on their behalf? Has the patient/guardian consented for their personal and clinical information to be provided Yes No to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the patient’s life may be in danger. Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Prior approval is required for all open and standing MRI scans. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at . Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration of treatment Please Tick Please indicate type of scan is requested: Open Standing Annual scan Please provide details of the purpose of the scan and why it is appropriate? Is the application on the basis of the patient being claustrophobic? YES NO If so has the patient been reviewed by the Radiology Department and YES NO discussed their concerns regarding MRI scanning to alleviate any fears? Has the patient sedation and failed to tolerate the MRI scan? YES NO Has the patient tried sedation and failed to tolerate the MRI scan in a YES NO wide bore MRI scanner? Was sedation offered under clinical supervision (oral sedation)? YES NO Have other modalities e.g. CT scan been considered as an alternative if YES NO suitable? Has the Radiology Department formally assessed the patient and YES NO found them unsuitable (e.g. due to the habitus of the patient and the restriction of the MRI scanner)? Please provide details of the patient’s Body Mass Index (BMI): Details of the habitus of the patient:
Procedure that requires prior approval Application form: - MRI Scanning – Open / Standing / Annual Name of Referring Clinician GP Name and Surgery Patient NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? Yes No Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Yes No Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the patient’s life may be in danger. Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Prior approval is required for all open and standing MRI scans. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at . Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration of treatment Please Tick Please indicate type of scan is requested: Open Standing Annual scan Please provide details of the purpose of the scan and why it is appropriate? Is the application on the basis of the patient being claustrophobic? If so has the patient been reviewed by the Radiology Department and discussed their concerns regarding MRI scanning to alleviate any fears? Has the patient sedation and failed to tolerate the MRI scan? Has the patient tried sedation and failed to tolerate the MRI scan in a wide bore MRI scanner? Was sedation offered under clinical supervision (oral sedation)? Have other modalities e.g. CT scan been considered as an alternative if suitable? YES NO YES NO YES NO YES NO YES NO YES NO Has the Radiology Department formally assessed the patient and found them unsuitable (e.g. due to the habitus of the patient and the restriction of the MRI scanner)? Please provide details of the patient’s Body Mass Index (BMI): Details of the habitus of the patient: YES NO
MRI-Scan-BW-v1.1.docx