Forms for SNF/Rehab Hospitals

SNF/Rehab Scheduling/Order Form

SNF/Rehab Scheduling Instructions Packet

Forms for Home Health, Group Homes, Day Programs, Assisted and Independent Livings

Outpatient Scheduling/Order Form

Outpatient Scheduling Instructions Packet

MTI Referral & Scheduling Process

1. Submit necessary paperwork including, the “Scheduling/Order Form” with consent, a face sheet, H&P, and medication list.

Physician Orders and Telephone Orders can also be on their letterhead. Please make sure the orders include three components: Dysphagia consultation, MBSS and esophageal assessment to stomach.

Send via fax #978.279.1066 or email to mbssonline@massteximaging.com

2. Receive a confirmation call or text from scheduling team of the submitted Order Form(s) & necessary paperwork. MTI team member will let you know if any documentation is missing.

3. Upon insurance verification, the MTI scheduler will arrange for your patient to be seen on the next available Mobile Clinic serving your area. The contact listed on “Scheduling/Order Form” will receive a call and/or text from the MTI scheduler the day before the appointment with a “two hour” time window of the consultation. Please confirm with our scheduling team upon receiving this call and/or text.

Forms for Infants and Young Pediatrics (birth- ~5 years)

Infant/Pediatric Scheduling/Order Form

Helpful Information

Recovered COVID-19 Information

What To Expect on The Day of Consultation

1. The MTI medical team will call and/or text the listed contact 20-30 minutes prior to their arrival. If you need more advance notice of arrival, please note it on the order form.

2. Please have the patient up in the wheelchair (if non ambulatory) and ready to come outside to the mobile unit. This includes appropriate clothing/blanket during inclement weather.

3. Please provide current height, weight, and vitals along with the H&P and medication list (if not already provided by fax).

4. If your patient is ventilator dependent, a respiratory therapist or nursing staff must accompany patient and remain on the clinic during the dysphagia consultation with a backup battery. If portable O2, please set up prior to arrival.

Contact the MTI Scheduling Team

Contact our scheduling team with any questions regarding our services, orders, or scheduling at 800.508.6277 or email us at mbssonline@massteximaging.com.