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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Scale of Fees

Annual Increase in Medical Tariffs for Medical Service Providers - 2019

Doctors

Annexures

Annexure A : MRI Motivation Form for Employee's Injured on Duty

 

Annexure: A

 

The Department of Labour: Compensation Fund

 

MRI Motivation Form for Employee's Injured on Duty

 

Claim Number:

 

 

 

Employee's Name:

 

 

 

Employees ID No:

 

 

 

Name of Employer:

 

 

 

Date of Accident/Injury:

 

 

 

Type of injury:

 

 

 

Brief description of how injury occurred:

 

 

 

Previous clinic/imaging investigations done, and dates:

 

 

 

Imaging investigation required:

 

 

 

Motivation/Clinical indications for the investigation:

 

 

 

Requesting Doctors Name:

 

 

 

Practice Number:

 

Date of Referral

 

 

This form should preferably be typed.