To refer a worker’s scans for an IRO, please complete this form and return it, along with a copy of all relevant documentation to referral@mrinow.com.au
Insurer/Employer:
CM Phone No:
CM E-Mail:
Postal Address:
Case Manager (CM):
CM Fax No:
Claim No:
Date IRO Required by*:
*Urgent IROs required within 3 business days will incur a supplementary fee. Standard IROs take up to 7 business days from receipt by the radiologist of the scans/CD.
Worker Name:
Worker Phone Number:
Worker Address:
Current Employer:
Mechanism of Injury:
Worker DOB:
Date of Injury:
Occupation:
Scan type to be Reviewed*:
Name of Radiology Centre where scan was performed:
Body part:
Date of Scan^:
If you do not have a copy of the scans on a CD and require MRI Now to obtain the CD, please ensure you provide us with the attached Patient Release Form .
*Eg, MRI, CT etc. ^Please note that a review of more than one scan in relation to the same injury/body part will incur a supplementary fee.
Please provide the following documents as part of your request for an IRO:
Injury/Incident Report Signed patient release form
Clinical Reports or medical reports of Patient’s condition Outline of work history
Medical history (including outline of previous injuries)
CD of worker’s scans (if obtained already)
Any other relevant information
List of questions for Radiologist

AUTHORITY TO RELEASE RADIOLOGY FILMS / CD
Patient Name:
Patient DOB:
Patient Address:
Date of Scan:
Scan Type & Body Part:
Radiology Centre:
Authority for the release of radiology films
I, , consent to the radiology centre listed above to release a copy of the above listed films to MRI Now. Please arrange for a CD containing my scan to be sent to MRI Now as soon as possible to the address below or an alternative address if nominated by MRI Now:
MRI Now
Level 12, Suite 18
95 Pitt Street
SYDNEY NSW 2000
Patient Signature
/ /
Date