What the High Risk OBSP requisition is for
It refers a patient for annual high-risk breast screening: mammography with breast MRI, or screening breast ultrasound when MRI isn’t medically appropriate. By signing, you authorize the initial and ongoing annual screening and any follow-up imaging and biopsies for abnormal results. It doesn’t order a diagnostic mammogram for a symptomatic patient, and patients with symptoms aren’t eligible.
Who completes it
The referring family doctor or nurse practitioner completes all three sections and signs. The patient has no section. Before referring, you talk to the patient about breast health and screening options, and refer only people who meet Category A or B.
How to fill in the requisition
Patient information
Name, date of birth, OHIP number, phone numbers and address, or affix a label.
Category A: direct entry
Tick at least one: a known carrier of a pathogenic or likely pathogenic variant such as BRCA1, BRCA2, TP53 or PALB2; a first-degree relative of a carrier who had genetic counselling and declined testing; a lifetime risk of 25% or more assessed by a genetics clinic with IBIS or CanRisk; or chest radiation before age 30 and at least eight years ago. Fax the genetic results or risk assessment with the form, and enter the IBIS or CanRisk 10-year and lifetime figures.
Category B: genetic assessment required
Tick at least one family or personal history criterion. These include a known variant in a close blood relative, breast or ovarian cancer plus another breast, ovarian, prostate or pancreatic cancer on the same side of the family, breast cancer at 35 or younger in the family, and a personal history of breast cancer at 45 or younger. The form defines close blood relative, same side of the family and limited family structure on page 2.
Clinical history
Give the date and location of the last mammogram and any MRI, attaching the report if you have it, and answer the questions on previous breast cancer, implants, and prior genetic assessment.
Referring provider
Your name, CPSO or CNO number, address, phone, fax, signature and date.
Common reasons it’s sent back
- Category A ticked with no genetic results or risk assessment attached.
- A risk estimate from a tool other than IBIS or CanRisk, or not done by a genetics clinic.
- A patient outside the 30 to 69 age range.
- A patient with breast symptoms, who needs diagnostic imaging instead.
- No category ticked.
Submitting and who pays
Fax the requisition, the latest mammogram report, and any genetic results to a High Risk OBSP site in your area. Cancer Care Ontario lists the sites on its High Risk OBSP page. The site books screening for Category A patients and refers Category B patients for genetic assessment, then recalls participants every year. Screening for eligible high-risk patients is covered by OHIP.