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MTM Treatment Application

Treatment Application

Treatment Application
 
 
     
 

Medical Treatments Management is not required by US national or California state law to abide by HIPAA requirements. All information is held privately and securely, we take the privacy of your personal medical records very seriously.

I give my permission for a MTM representative to review my Treatment Application and PHR for completeness before securely transmitting it to the specialists for evaluation. I have read and understand the Medical Treatments Management Terms and Conditions.
I accept the MTM Terms and Conditions:

General Information









Home Phone:

Date of Birth (MM/DD/YYYY): Gender:


Occupation:


Treatment Information

Please briefly describe the treatment and procedure you are being evaluated for, including what if any medical treatment(s) you’ve received for your condition, and any diagnoses or lab results you have received. We have provided a list of Specialties and the corresponding Treatment and Procedure. Please provide multiple treatment requests in the space provided.
Treatment and Procedure Description:



Specialty:
Treatment Procedure:
Proposed Treatment Date (MM/DD/YYYY):

Do you have recent existing Medical Records such as x-rays, CT-scans, lab results, existing prescriptions and other Medical Images in Electronic Format?

I have completed and sent MTM my
Personal Health Record (PHR):

Have you discussed your options locally with your Primary Care Physician?   
Is your Primary Care Physician willing to provide pre and post treatment care?
Do you have health care support options available to you at your home?         

Primary Care Physician Name: 
Primary Care Physician Email: 
Primary Care Physician Phone:


Treatment Package Options

Options you may want to consider adding to your customized package design, each is separated by cost for your review.
MTM Service Options:
Wellness Option One:
Wellness Option Two:
Health Products Option One:
Health Products Option Two:


Additional Information

First Preferred Country of Treatments:    
Second Preferred Country of Treatments:
Will you have a Travel Companion?                   How Many Travel Companions:
Provide Air and Ground Transportation:              Provide Accommodations:      
Provide Food Plan:
How many additional days in destination country outside of the Hospital stay:
Do you have valid Passports:                       Do you have any Travel Disabilities:
Payment Type:





 
     
 
 
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