Physicians use this three-page requisition to order ultrasound, CT, MRI or interventional procedures for a worker with a WorkSafeBC claim, and WorkSafeBC's specialist requirements page lists it as the diagnostic imaging referral form. It records the exact examination, prior imaging, medical history, contrast and MRI safety screening, anticoagulant details for interventional procedures, and where copies of the report go.
The ordering physician, whether specialist or primary care, completes the requisition in ink and signs it with their MSP number.
Download the current version from the source each time; forms change without notice.
Requisition for Medical Imaging (Form 83D56)
This form isn’t published as a fillable PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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The requisition's criteria require at least one of: significant or progressive neurological deficits, risk factors for infection or tumour, radicular pain or neurogenic claudication lasting over 12 weeks, previous lumbar surgery with another criterion met, or an MRI recommended on a previous imaging report. MRI is not indicated for acute mechanical low back pain.
Not always. For patients 40 and older, the form says MRI mainly serves surgical planning and adds little in moderate to severe osteoarthritis, so a weight-bearing X-ray is recommended. If the X-ray shows mild or no osteoarthritis, a specialist referral is recommended and a pre-consult MRI is not required.