Procedure that requires prior approvalApplication form: - MRI Scanning – Open / Standing / Annual(Policy 64)
Name of Referring ClinicianGP 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: 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 which type of scan is requested:
☐Standing/Upright
- Please provide details of the clinical need for this procedure?
- 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 tried 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?
- Have other modalities e.g. CT scan been considered as an alternative if suitable?
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)?
BMI / kg/m2
Height / cm
Weight / kg
Please can the Radiograph to provide evidence regarding issues of size: / YES ☐ NO ☐
- Is the patient a non-smoker?
SIGNATURE OF CLINICIAN …………………………………………………………….DATE: …………………………………………………..
Please email the completed form to for consideration.
South, Central and West Commissioning Support Unit July 2017 64BD