What the R250-10-116 is for
This is the requisition for diagnostic imaging at facilities outside Winnipeg that aren’t affiliated with Central Intake. Shared Health’s current guidance limits it to X-ray, ultrasound and nuclear medicine. CT moved to its own standardized form in January 2026, and MRI, PET, mammography, breast ultrasound and bone density each have a separate form. Requests from a rural site for an exam at a rural site go straight to that site, not through Central Intake.
Who completes it
The ordering clinician completes the clinical sections and signs the authorized clinician block. The imaging department completes the office use and coding area and books the appointment.
How to fill in the request
Patient and location
Enter the patient’s name, contact number, date of birth and health card number, and tick ED outpatient, outpatient or inpatient. For outpatients, choose first available in Winnipeg, willing to travel within Manitoba, or preferred sites. Note who will follow up the result, the emergency physician or the family physician, and give the date the exam is needed.
History and examination requested
Select one modality, name the exam, and list previous relevant exams with dates and locations. Choose emergent, urgent or elective, or give a specific date. For emergent exams, contact the radiologist directly. The history and provisional diagnosis box carries the request, so state the clinical question as well as the symptoms.
Mobility and precautions
Tick how the patient travels: ambulatory, wheelchair, stretcher, geri chair, bed, portable, or needing a lift. Answer the TB question and mark any infection control precautions: droplet, contact, airborne, or the protective options.
Contrast, pregnancy and renal risk
For contrast-enhanced exams, give an accurate weight when the patient is over 400 lbs, plus height. Answer the contrast allergy, pregnancy and nursing questions and give the last menstrual period. Tick any renal risk factor listed, such as kidney disease, diabetes, myeloma, age over 65 or metformin and NSAID use, and give the latest creatinine and eGFR with the date. For invasive procedures, add INR and platelets from within 24 hours of the exam.
Authorized clinician information
Print and sign your name, and add your MHSC billing number, address, phone, fax and the date. Use the extra report line for a second clinician who should get the result.
Common reasons it’s delayed
- A CT ordered on this form instead of the R250-10-115.
- An exam for a Winnipeg site sent to a rural department rather than Central Intake.
- No history or provisional diagnosis, or only a symptom with no question.
- Renal risk factors ticked with no creatinine result.
- Missing INR or platelets for an invasive procedure.
- No billing number or an unsigned form.
Submitting and who pays
Fax the completed form to the imaging department doing the exam, using Shared Health’s fax contact sheet. Medulla can suggest this requisition when the visit plan orders imaging.