EZ Referral Service Request RushYesNoSelect Service Type(s)* Transportation - MTiRide Durable Medical Equipment Language Services Home Health & Catastrophic Care Diagnostic Services Post-Acute Care Physical Medicine Services Dental Services Flight & Hotel Accommodations Requestor RequestorFirst Name*Last Name*Requestor Title*Please ChooseClaim AdjusterNurse Case ManagerReferring DoctorAttorneyIME CompanyOtherTitle: Other*Phone*Mobile PhoneEmail* Remember Me Nurse Case ManagerNCM First NameLast NamePhoneMobile PhoneEmail PayorPayorCompany*Phone*Address*Adjuster on the FIleFirst Name*Last Name*Phone*Mobile PhoneEmail* PayorCompany*Phone*Address*Adjuster on FileFirst Name*Last Name*Phone*Mobile PhoneEmail* Nurse Case ManagerFirst NameLast NamePhoneMobile PhoneEmail PayorCompany*Phone*Address*Patient Patient InfoFirst Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY HeightMTI asks this information to reduce the number of touchpoints to the adjuster/nurse to increase scheduling speed. The height and weight also help us personalize the patient experience and ensure they receive the right level of care.WeightMTI asks this information to reduce the number of touchpoints to the adjuster/nurse to increase scheduling speed. The height and weight also help us personalize the patient experience and ensure they receive the right level of care.Phone*Email AddressInjuryInjury Date* Date Format: MM slash DD slash YYYY Employer Name*Claim#Injury StatePlease ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificClaim is Compensable? Yes No Injury DescriptionPhysicianPhysicianFirst NameLast NamePhoneFaxEmail AddressServices Transportation (MTiRide)Trip Type*One WayRound TripMultiple StopsTransportation Type* Sedan - Patient is able to walk, and get in and out of their vehicle on their own or only need basic assistance. Wheelchair Lift - A van equipped with a lift and a mechanism to secure a wheelchair, the transport specialist wheels the patient to the van, safely raises the patient into the van on the lift and secures the patient's wheelchair Stretcher - Patient is immovable or is advised to not bear any weight or walk without the help of any assistance. Air Ambulance - Fixed-wing aircraft used to move patients over long distances. Different levels of medical flight crew. Ambulatory (Sedan Service)Wheelchair LiftStretcherAir AmbulanceAppointment Date* Date Format: MM slash DD slash YYYY Appointment Time*Appointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherOtherNetwork OptionPlease ChooseNo Network PreferenceRide Share: LyftMTI Proprietary NetworkOrigin Same as Patient Address? Yes Address*DestinationFacility Name*Facility Phone*Facility Address*Multiple Stop Address 1*Multiple Stop Address 2*Multiple Stop Address 3*Multiple Stop Address 4*Are there multiple appointments? Yes No How many appointments?12345Is the destination the same as above Yes No Destination AddressAdditional Notes Specific Pick Up Arrangements Prefer Male or Female Driver Employee lives in a three-story building and needs help getting downstairs. Language ServicesAppointment Date* Date Format: MM slash DD slash YYYY Appointment Time*Translation Type*Please ChooseOn-Site interpretationTelephonic interpretationVideo Remote (VRI)Document translationTranscriptionAppointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherOtherRequested LanguagePlease ChooseSpanishCreoleSign LanguageArabicVietnameseOtherOtherFacilitySame Facility as Transportation Yes Facility Name*Facility Phone*Facility Street Address*City*State*Please ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*QualificationPlease ChooseLegal CertifiedQualifiedCertifiedNo preferenceQualificationQualifiedPhysicianFirst NameLast NamePhoneAdditional Notes For Example: Male or Female Translation Specialist Meet in the Patient Lobby Dialect Request Physical MedicinePost Surgery Yes Service Request*Please ChoosePhysical TherapyOccupational TherapyFunctional Capacity Evaluation (FCE)Working ConditioningWorking HardeningAquatic TherapyCertified Hand Therapy (CHT)Ergo/Job SiteFCE-Upper Extremity OnlyFCE-with Impairment RatingImpairment RatingTelerehabilitationAI - TelerehabilitationBody Part InjuredTotal Visits You Are AuthorizingTransportation Required Yes Translation Required Yes Additional NotesFor Example: Employee prefers PT appointments located near work Preferred Facility Please inform us of your preferences, whether you prefer in-person or virtual appointments, your preferred gender of provider, and any other preferences you may have.Please upload the prescription and any other supporting documentation below: Drop files here or TransportationTrip Type*One WayRound TripMultiple StopsTransportation Type* Sedan - Patient is able to walk, and get in and out of their vehicle on their own or only need basic assistance. Wheelchair Lift - A van that's equipped with a lift and a mechanism to secure a wheelchair, the transport specialist wheels the patient to the van, safely raises the patient into the van on the lift and secures the patient's wheelchair Stretcher - Patient is immovable or is advised to not bear any weight or walk without the help of any assistance. Air Ambulance - Fixed-wing aircraft used to move patients over long distances. Different levels of medical flight crew. Please ChooseAmbulatory (Sedan Service)Wheelchair LiftStretcherAir AmbulanceAppointment Date Date Format: MM slash DD slash YYYY Appointment Time*Appointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherAppointment Type: OtherNetwork OptionPlease ChooseNo Network PreferenceRide Share: LyftMTI Proprietary NetworkOriginAddress*DestinationFacility Name*Facility Address*PhoneAre there multiple appointments? Yes How many appointments?12345Is the destination the same as above Yes No Destination AddressAdditional Notes Specific Pick Up Arrangements Prefer Male or Female Driver Employee lives in a three-story building and needs help getting downstairs. Language ServicesLanguage Appt Date Date Format: MM slash DD slash YYYY Appointment Time*Translation Type*Please ChooseOn-Site interpretationTelephonic interpretationVideo Remote (VRI)Document translationTranscriptionAppointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherAppointment Type: OtherRequested LanguagePlease ChooseSpanishCreoleSign LanguageArabicVietnameseOtherRequested Language: OtherFacility Name*Facility Phone*Facility Street Address*City*State*Please ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*QualificationQualifiedQualificationPlease ChooseLegal CertifiedQualifiedCertifiedNonePhysician First NameLast NamePhoneEmail FaxAddressAdditional Notes For Example: Male or Female Translation Specialist Meet the Patient Lobby Dialect Request Home Health & Catastrophic CarePlease indicate services, if known. Services Nursing RN Nursing LPN/LVN Home Health Aide/CNA IV Therapy In-Home Speech Therapy In-Home Physical Therapy In-Home Occupational Therapy Companion Wound Care IV Therapy Home & Vehicle Modification Prosthetics Service Location Type Home service Location Type Facility Other OtherAddress*Hospital Discharge Date Date Format: MM slash DD slash YYYY Hospital Phone NumberContact PersonWill this patient require medical equipment and supplies? Yes Additional NotesPlease upload the prescription and any other supporting documentation below: Drop files here or Durable Medical Equipment Purchase Rental (if available) Delivery Location Address*Delivery To: Home Delivery To: Facility DME ProductPlease ChooseCold Compression Systems/Cold Therapy UnitsWound suppliesElectrotherapyWalkersCrutchesOtherOtherSpecialty Medical EquipmentSpecialty Medical EquipmentPlease ChooseProstheticsCustom WheelchairsHome ModificationGrab BarsRampsOtherOtherAdditional Notes / Other Products / Product Details For Example: Where to deliver the package if know one is home Times when employee is home Please upload the prescription and any other supporting documentation below: Drop files here or Diagnostic ServicesIs this a STAT Order? Yes Transportation Required Yes Translation Required Yes Procedure*Please ChooseMRIMRI with ContrastEMGCTX-RaysArthrogramsBone ScanUltrasoundMyelogramPhysicianFirst Name*Last Name*Phone*Additional NotesFor Example: Please include any pre-screening concerns and scheduling instructions Please upload the prescription and any other supporting documentation below: Drop files here or TransportationTrip Type*One WayRound TripMultiple StopsTransportation Type* Sedan - Patient is able to walk, and get in and out of their vehicle on their own or only need basic assistance. Wheelchair Lift - A van that's equipped with a lift and a mechanism to secure a wheelchair, the transport specialist wheels the patient to the van, safely raises the patient into the van on the lift and secures the patient's wheelchair Stretcher - Patient is immovable or is advised to not bear any weight or walk without the help of any assistance. Air Ambulance - Fixed-wing aircraft used to move patients over long distances. Different levels of medical flight crew. Please ChooseAmbulatory (Sedan Service)Wheelchair LiftStretcherAir AmbulanceAppointment Date Date Format: MM slash DD slash YYYY Appointment Time*Appointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherAppointment Type: OtherNetwork OptionPlease ChooseMTI Proprietary NetworkRide Share: LyftNo Network PreferenceOriginAddress*DestinationFacility Name*Facility PhoneFacility Address*Are there multiple appointments? Yes How many appointments?12345Is the destination the same as above Yes No Destination AddressAdditional Notes Specific Pick Up Arrangements Prefer Male or Female Driver Employee lives in a three-story building and needs help getting downstairs. Language ServicesAppointment Date* Date Format: MM slash DD slash YYYY Appointment Time*QualificationPlease ChooseLegal CertifiedQualifiedCertifiedNoneTranslation Type*Please ChooseOn-Site interpretationTelephonic interpretationVideo Remote (VRI)Document translationTranscriptionAppointment TypePlease ChooseDoctor's AppointmentPhysical TherapyIMEMRIDepositionOtherOtherRequested LanguagePlease ChooseSpanishCreoleSign LanguageArabicVietnameseOtherRequested Language: OtherFacility Name*Facility Phone*Facility Street Address*City*State*Please ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*Physician First NameLast NamePhoneEmail FaxAddressAdditional Notes For Example: Male or Female Translation Specialist Meet the Patient Lobby Dialect Request Dental ServicesService TypePlease ChooseEvaluation & TreatmentIMEIn-House ReviewFee AuditPeer ReviewSecond OpinionTreatment CoordinationOtherAdditional NotesPlease upload supporting documentation below: Drop files here or Example Documents: Discharge Note, Urgent Care Notes, Treating Notes, Work Comp Summary, Prior Imaging Study, Sign Medical Release, Dental & Medical recordsAir & Hotel AccommodationsTravel AccommodationsPlease ChooseFlightHotelGround transportationBusTrainAppointment Date* Date Format: MM slash DD slash YYYY Appointment Time*Appointment TypePlease ChooseDoctor's AppointmentIMEAMEQMEHospital/Rehab TransferOtherAppointment Type: OtherFacility Name*Facility PhoneFacility Address*Do you need a medical escort? Yes Additional Notesp>Example Documents: Specific Travel Accommodations Provide any additional information Please upload supporting documentation below: (Drag and Drop your files below) Drop files here or Post-Acute CareRequested provider Information Requested Physician Guidelines: ONLY for Pain Management, Post-Acute Care, Addiction Recovery or Behavioral Health.Physician NameGroup NameSpecialtyEmail PhoneFaxAdditional Information for Post-Acute Care OnlyCurrent FacilityFacility NameContact NamePhoneAddressAnticipated Discharge Date Date Format: MM slash DD slash YYYY New Facility nameNew Facility PhoneRequested Facility GuidelinesAdditional Information for Addiction Recovery OnlyInitial Plan of CarePlease upload the prescription and any other supporting documentation below: (Drag and Drop your files below) Drop files here or Δ Other Ways You Can Refer 800-553-2155 referrals@mtiamerica.com Chat with a live agent Want to make the EZ Referral a shortcut on your desktop? 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