Mobile Dysphagia Consultants Your Mobile Partner in Swallowing Disorders

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Mobile Dysphagia Consultants Your Mobile Partner in Swallowing Disorders To Schedule a Dysphagia Consultation Please FAX the Order Form(s) to 978.279.1066 (All forms can be downloaded at www.massteximaging.com) 800.508.MBSS (6277) P 978.750.0300 F 978.279.1066 www.massteximaging.com mbssonline@massteximaging.com Out Patient, Home Care, Assisted Living Facilities, Dayhabs, Group Homes and Physician Offices 1. A COMPLETED ORDER FORM to include: Physician/NP/PA Orders: You may use the MassTex Imaging ORDER FORM by having the ordering MD, NP or PA sign section 6b (Please print their name legibly in section 6a per Medicare Guidelines) or the MD/NP/PA can submit their own order form. Medical History/Clinical Information: Please fill sections 7 through 10 completely for the Physician to review prior to seeing your patient. Insurance Information: For Managed Care Patients, MassTex Imaging will contact you and assist with the authorization process. Face Sheet/Demographic Data/Emergency Contact Sheet from the patient s medical record or chart. Scheduling Restrictions: Please indicate any scheduling restrictions in section 11 Scheduling Restrictions and we will do our best to accommodate the patient s needs. Please note that scheduling restrictions may delay the scheduling of your patient. 2. A COMPLETED CONSENT FORM to include: Verbal Consent: The patient s or the invoked Health Care Proxy s consent to the consultation/procedure. Party Who Obtained Verbal Consent: Legibly printed name, title and signature. 3. FACILITIES WITH ELECTRONIC MEDICAL CHART please fax the following: History and Physical (H&P): Copy of the most recent and complete H&P. If the patient is a long-term patient that has not had an H&P recently, please send a recent progress note as a second option. Medications Along with Allergies: List of current medications and any known allergies. 4. UPON MTI RECEIPT of FAXED ORDER FORM(S) and necessary documentation: Order Form(s) Confirmation: The referring clinician or scheduling contact will receive a same day confirmation call or text confirming receipt of order form(s) as well any missing documentation. Appointment scheduling: The day before the scheduled appointment the scheduling contact will receive a phone call confirming the two hour time window for the Dysphagia Consultation. Please note, if a cancellation occurs on the day your patient is being seen an earlier arrival time may occur prior to the two hour time window. You will be notified if the time window changes. 5. CANCELLATION POLICY: Please notify MassTex Imaging immediately if the Dysphagia Consultation needs to be cancelled. Failure to notify us may result in a travel/cancellation fee to your facility should we arrive and the patient is not on the premises. Form Version 1.1 6/2016

Mobile Dysphagia Consultation Order Form (For Out Patient, Home Care, Assisted Livings, Dayhabs, Group Homes & Physician Offices) Once Completed Fax to MassTex Imaging at 978.279.1066 with FACE SHEET, CONSENT & H&P (1) EXAM TO BE SCHEDULED AT Private Residence Dayhab Assisted Living Other Facility Name (if applicable) Street Address Apt/Bldg/Unit City State (2) SCHEDULING CONTACT (For preliminary arrangements and day of exam contact) Name Relation to Patient Primary Contact # Secondary # (3) INSURANCE INFORMATION Medicare A Medicare B Medicare # Medicaid Indicate State Medicaid # Other Policy (4) PATIENT DEMOGRAPHICS Name DOB Sex Height Weight SS # Can Patient Consent for Self Yes No Health Care Proxy Invoked Yes No (5) TREATING SLP/OT/RN Name Cell # Text Yes No Best Contact # Email Agency Address (6a) ORDERING PHYSICIAN *NAME REQUIRED* (PRINT LEGIBLY) First Name Last Name Practice Name Address Phone # (6b) PHYSICIAN ORDER Dysphagia Consultation Including MBSS and Esophageal Assessment to Stomach Ordering MD/NP/PA Signature Date NPI Electronic Orders & Signed Orders on Facility Forms are also Accepted Printed Name of Signing Party *If different from section 6a* First Last (6c) Reason(s) Mobile/Onsite Visit is Required Emergent request due to elevated aspiration risk Transport negatively impacts underlying physical condition Fatigues easily, compromising test participation Transport exacerbates behavioral problems and compromises test participation Diagnosis (7) MEDICAL HISTORY (Check all that apply) CVA CHF COPD Developmental Delays Intellectual Impairment Parkinson s GERD Alzheimer s Dementia TBI/CHI Head/neck cancer Other Respiratory Status WFL O-2 Trach Type Size Vent Speaking valve CONTACT PRECAUTIONS Yes No If yes, reason Food Allergies Yes No If yes, list (8) MEDICAL NECESSITY FOR CONSULT (Check all that apply) Breathing difficulty w/ PO intake Pain on swallowing Coughing Choking Poor PO intake Dehydration Respiratory distress Feeding Difficulties Shortness of breath Food/pills getting stuck S/S of silent aspiration Gagging Tearing with oral intake Esophageal reflux Vomiting Globus sensation Weight loss Heartburn Wet vocal quality Malnutrition Wheezing with PO intake Moist cough Other Duration of Symptoms New Onset Days Weeks Months Other Goals Determine least restrictive diet Determine safest diet Pre-treatment evaluation Determine appropriate swallow maneuvers/strategies Frequency of Symptoms All PO Liquids Solids Pills Saliva Other Status Change Due To Weight loss Malnutrition Reduced PO Increased awareness Decreased awareness Improved swallowing Decline in swallowing (9) SWALLOWING TREATMENT Not on caseload for dysphagia New Evaluation E-Stim Thermal Stim O-M ex. Pharyngeal ex. Candidate for Strategies Yes No (10) CURRENT DIET NPO Gtube Jtube NGT Solids Liquids Trials Current Strategies: (11) SCHEDULING RESTRICTIONS 800.508.MBSS (6277) p 978.750.0300 mbssonline@massteximaging.com www.massteximaging.com (Ver 1.3 6/2016)

Consent, Authorization & Release of Information: * If the patient cannot consent for him/herself, CONSENT from either the invoked Health Care Proxy (HCP) or legal guardian for the patient must be obtained.* Patient Name: DOB: MassTex Imaging, LLC has my consent to perform a Dysphagia Consultation and X-Rays including a Modified Barium Swallow Study (MBSS) and Esophageal Assessment to the Stomach. I authorize insurance benefits to be paid directly to MassTex Imaging and acknowledge that I am responsible for any balance that may not be covered, including co-pays and deductibles. MassTex Imaging, LLC has my consent to release Protected Health Information (PHI), medical records, portal access and reports as pertaining to the Dysphagia Consultation, Modified Barium Swallow Study (MBSS) and Esophageal Assessment to the Stomach, to my insurance company and the referring physician and referral source. Swallow studies may be used for research, publication, and/or educational purposes. No identifying information will be disclosed without specific written consent. Please list anyone else, other than the referring physician / clinician you would like the information to be released to: (name & relation to patient) Please Complete Verbal OR Written Consent Verbal Consent Verbal Consent Given By: Relation to Patient: Patient Guardian / POA Health Care Proxy Printed Name & Title of Person RECEIVING Verbal Consent: Signature of Person RECEIVING Verbal Consent: Date Consent Obtained: Written Consent Printed Name of Person Giving Consent: Relation to Patient: Patient Guardian / POA Health Care Proxy Signature: Date: 3 Electronics Avenue, Suite 201, Danvers, MA 01923 800.508.MBSS (6277) P 978.750.0300 F 978.279.1066 Form Version 2.4 6/15/2016

Patient Information from MassTex Imaging, LLC Regarding Consent for a Dysphagia Consultation including Modified Barium Swallow & Esophageal Assessment to Stomach Your physician has ordered a Dysphagia Consultation which may include a Modified Barium Swallow & Esophageal Assessment to the Stomach via videofluoroscopy. This order has been sent to MassTex Imaging, LLC, a Mobile Medical Practice. A Dysphagia Consultation including MBSS and Esophageal Assessment to the Stomach will only be carried out with verbal or written consent provided by you or your health care proxy (if invoked). What is a Dysphagia Consultation, Modified Barium Swallow and Esophageal Assessment to the Stomach? A Modified Barium Swallow (MBSS) and Esophageal Assessment to the Stomach are video x-rays that allow us to examine your oral, pharyngeal and esophageal swallow mechanisms. Video x-rays (Videofluoroscopy) allow us to watch you swallow as it happens by watching liquid and food mixed with barium travel from your mouth into the stomach. These assessments will provide information about the cause of your swallowing difficulty and whether food or liquids are going into your airway. As part of the consultation, this information is then used by our clinical team to recommend how best to improve your safety and comfort while swallowing. Additionally, this information is also used to help plan your swallowing therapy plan of care. What will happen? Our mobile medical clinic will come to your location. Our driver technician will bring you onto our mobile clinic and you will be seated beside the x-ray machine. You will not be asked to lie down. Family members and your medical team are welcome to attend with your permission. The MassTex Imaging Speech Pathologist will give you foods and liquids to swallow. These food and liquids will be mixed with barium. Barium is used because it is easily seen under x-ray. Barium is chalky but not unpleasant and you will only be given small amounts. You may be asked or helped to change your position on the seat. Our physician will record each swallow digitally. Our Physician will exam you as well as review your medical record to determine health risks that may increase your risk of developing an aspiration pneumonia, review the medications you are currently taking to determine if they may affect your swallow mechanism, recommended further consultations as needed and provide diet, strategies and therapy recommendations to help you and your medical team manage any swallowing problems identified. Once the consultation is concluded you will be shown back to your room. The Physician and Speech Pathologist will then type a detailed report. These reports along with a DVD with audio of your videofluoroscopy x-ray exams will be sent to your medical team and referring physician. Are there any risks or side-effects? This is a painless procedure and you may eat and drink normally before and after your appointment. Barium is harmless. It can cause a little constipation but this can be avoided by drinking plenty of fluid for the rest of the day after your consultation. Your stools may be paler than usual for the next few days. This is nothing to be alarmed about. It is just the barium passing through your system. All x-ray procedures involve some exposure to radiation and, as such, pose a degree of risk. Everyone is exposed to natural background radiation from the environment throughout their lives. One in 3 people will develop cancer at some point in their lives due to many various causes including environmental radiation. Radiation from a medical procedure involving x-rays can add very slightly to this risk. The length and level of exposure to radiation from x- rays in medical procedures is very strictly controlled and is kept to the minimum amount possible. The added risk of cancer due to this radiation is extremely small. Your doctor has determined that the risk to your health of not having this procedure is considerably greater than the risk from the radiation used. How is my medical information disclosed? Your verbal or written consent gives MassTex Imaging, LLC authorization to use and disclose your medical information to bill and collect payment for services and to release the dysphagia consultation and radiological exams to you referring medical team. Swallow studies may be used for research, publication and/or educational purposes. No identifying information will be disclosed for research/education or publication without written consent from you, maintaining strict confidentiality and HIPPA guidelines. If you have any inquiries or require further information about your upcoming Dysphagia Consultation please contact us at 800.508.MBSS (6277) or 978.750.0300 and we would be happy to answer any questions.

Mobile Dysphagia Consultants Your Mobile Partner Swallowing Disorders 800.508.MBSS (6277) P 978.750.0300 F 978.279.1066 www.massteximaging.com mbssonline@massteximaging.com Day of Dysphagia Consultation On the DAY of the appointment, the MassTex Imaging Medical team will call the listed contact 20 minutes prior to their arrival, allowing adequate time to prepare the patient for the appointment. Because cancellations do occur, we will notify you if we are going to be earlier than the given window of time. Please make sure that the patient as well as any family members or therapists attending the study be available earlier should this occur. Checklist Prior to Medical Team Arrival Patient is up and ready in a wheelchair with foot pedals or other chair to be transported onto the medical van. Please have the patient waiting in the lobby if possible. Medical record to be ready to be brought out to the Medical Van. Current height, weight and vitals from the day of visit. Portable O2 set up prior to arrival (if appropriate). If vent dependent, respiratory therapist or nursing staff must accompany patient and remain on the Medical Van during the consultation. Please make sure these staff members are ready and do not delay the consultation. Provide any feeding equipment such as spoons, cups, etc that the patient may be using during eating/drinking. Dentures in place if patient uses them to eat/drink. Patient is dressed appropriately for the weather, e.g. coat for cold weather. NOTE: MassTex Imaging needs to be notified immediately if the Dysphagia Consultation needs to be cancelled. Failure to notify us may result in a travel/cancellation fee to your facility should we arrive and the patient is not on the premises. We value the opportunity to assist you with the care of your patient. We look forward to providing your patients with a comprehensive dysphagia consultation specializing in MBSS, considered the GOLD Standard in swallowing studies along with a Physician Consultation and an Esophageal Assessment to the Stomach. If you have questions please feel free to contact us. We are happy to help. Thank you, The MassTex Imaging Team Form Version 1.1 6/8/15

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