Neurology New Patient Welcome Packet - Mount Sinai Hospital

Department of Neurology New Patient Welcome PacketDear Patient,For your convenience, we are pleased to send you copies of the Welcome Packet and Patient MedicalHistory Questionnaire. It is preferable that you return the completed forms prior to the date of visit.You will be receiving a reminder call from our automated service prior to your appointment.Please complete the attached paperwork beforehand, and fax it to the appropriate number listed below.If you cannot fax the forms, please be sure to bring it with you the day of your appointment.Please also make sure that the completed forms include both your primary and referring physicians’name, address and phone numbers, so that we can communicate with your providers.In addition, to care for you efficiently and avoid delays in evaluating your condition, it is essential thatyou bring with you the following:1) Your insurance card2) Applicable Medical Records3) X-ray reports, CD recording (including CAT scans, MRI’s, PET scans, ultrasound studies),recent laboratory reportsIt may be necessary for you to contact your primary or referring physician prior to your visit in order toobtain the above information. If your insurance carrier requires a referral, please make sure to contactyour primary physician and have his/her office fax it to us at the appropriate number below or submitit electronically.Below is your appointment information; directions to our office are attached.Your appointment is scheduled with:Appointment Date & Time:Locations:! Neurology FPA, 5 East 98 th Street, 7 th Floor (between Madison & Fifth Avenues)Tel: (212) 241-7076 Fax: (212) 860-4952! Movement Disorders, 5 East 98 th Street, 1st FloorTel: (212) 241-5607 Fax: (212)-241-3656! Corinne Goldsmith Dickenson MS Center, 5 East 98 th Street, 1st FloorTel: (212) 241-6854 Fax: (212) 241-5333! Mount Sinai Hospital, Annenberg Building 2 nd FloorTel: (212) 241-2179 Fax: (212) 987-3301Please do not hesitate to contact us, regarding your appointment or directions to our office.Department of NeurologyWe#appreciate#your#cooperation#in#completing#this#form."Once#this#form#is#complete,#please#fax#it#to#the#appropriate#number#listed#above#or#print#it#and#bring#it#with#you#to#your#appointment.###

Physician you are seeing:Dr. S. Babineau Dr. H. Bender Dr. B. Changizi Dr. C. Cho Dr. M. DhamoonDr. K. Elliot Dr. M. Fabian Dr. M. Fields Dr. G. Forster Dr. S. Frucht Dr. Y. Frank Dr. S. Gandy Dr. S. Gendelman Dr. M. Goldstein Dr. M. Green Dr. D. Horowitz Dr. S. Krieger Dr. F. Lublin Dr. L. Marcuse Dr. A. Miller Dr. B. Mintz Dr. K. Mullin Dr. R. Motiwala Dr. W. Olanow Dr. J. Robinson-PappDr. J. Rucker Dr. K. Sheinart Dr. D. Simpson Dr. M. Sivak Dr. C. StacyDr. W. Tse Dr. S. Tuhrim Dr. M. Velickovic Dr. J. Weinberger Dr. J. WoehrDr. L. ZhouLast name:#PATIENT INFORMATIONFirst:Middle:Appointment date:Birth date:Marital status: Single Married Divorced Separated Widowed Sex: M FStreet address/PO Box: City: State & Zip Code:Email address: Social Security #:Ethnicity: Hispanic Non-Hispanic Race: African-American Caucasian Asian American Indian OtherCell/Mobile phone:( )Check here if this is Preferred Contact # Home phone:( )Check here if this is Preferred Contact # Work Phone:( )Check here if this is Preferred Contact # Employer Name: Employer Address: Occupation:Pharmacy Name:Pharmacy Address:Pharmacy Phone: ( ) Pharmacy Fax: ( )REFFERAL SOURCEReferring Source (Please check all that apply): Physician/Clinic Family/friend Clergy Employer/Coworker 800-MD-SINAI Mount Sinai Website Insurance No Referring MD Self Other:Referral Name:Referral E-mail:Referral Address: Check if this is a second opinionReferral Phone: ( ) Referral Fax: ( )INSURANCE INFORMATION(Please present your insurance card to the receptionist.)Person responsible for bill:Birth date: Address (if different): Home phone no.: Self / / ( )Occupation: Employer: Employer address: Employer phone no.:( )Name of primary insurance:Subscriber’s name: Birth date: Group no.:Policy no.: SelfPatient’s relationship to subscriber: Self Spouse Child OtherSECONDARY INSURANCE (IF APPLICABLE)Name of secondary insurance: Subscriber’s name: Group no.: Policy no.:Patient’s relationship to subscriber: Self Spouse Child Other

IN CASE OF EMERGENCYPlease notify in case of emergency:Relationship to patient: Check if address is the same as in patient informationAddress: City, State: Zip:Home phone: ( ) Work/cell phone: ( )Primary Care Physician:OTHER TREATING PHYSICIANSAddress:Fax:( )Specialist Physician(s):Conditions Treated:Phone:( )Physician name: Specialty/Conditions Treated: Address:Phone: ( ) Fax: ( )Physician name: Specialty/Conditions Treated: Address:Phone: ( ) Fax: ( )Physician name:Specialty/Conditions Treated:Address:Phone: ( ) Fax: ( )Physician name: Specialty/Conditions Treated: Address:Phone: ( ) Fax: ( )Physician name:Specialty/Conditions Treated:Address:Phone: ( ) Fax: ( )The above information is true to the best of my knowledge. I authorize my insurance benefits bepaid directly to the physician. I understand that I am financially responsible for any balance, (seefinancial agreement). I also authorize the Neurology Faculty Practice Associates and/orinsurance company to release any information required to process my claims.Patient/Guardian signature:Date:Personal Representative Name:Personal RepresentativeAuthority:Responsible Party Signature:

Mount Sinai School of MedicineDepartment of NeurologyFinancial AgreementWe are committed to providing you with the best possible care and are pleased to discuss our professionalfees with you at any time. Your clear understanding of our Financial Agreement is important to ourprofessional relationship. Please ask if you have any questions about our fees, financial policy or yourfinancial responsibility.PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILLREQUEST TO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE.• REFERRALS – If your plan requires a referral from your primary care physician, it is YOUR responsibilityto obtain it prior to your appointment and have it with you at the time of your visit. If you do not haveyour referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER and will be personallyresponsible for that day’s services.• CO-PAYMENTS – By law we MUST collect your carrier designated co-pay. This payment is expected atthe time of service. Please be prepared to pay the co-pay at each visit.• OUT OF NETWORK PLANS – Since, we do not ‘participate’ with your plan and payment will beexpected at the time of service, unless prior arrangements have been made with our financial staffincluding co-insurance, deductible and non-covered amount. We will send a courtesy bill to the carrieron your behalf.Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned,authorize payment of medical benefits to Department of Neurology for any services furnished. I understandthat I am financially responsible for any amount not covered by my contract. I also authorize any holder ofmedical information about me to release to my insurance company (or their agent) information concerninghealth care, advice, treatment or supplies provided to me. This information will be used for the purpose ofevaluating and administering claims of benefits.• SELF-PAY PATIENTS – Payment is expected at the time of service unless other financial arrangementshave been made prior to your visit.• MEDICARE – We will submit claims to Medicare. The patient will be responsible for the deductible andthe 20% co-insurance, which can be billed to a secondary insurance if you have one.Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on mybehalf to the Mount Sinai School of Medicine Department Neurology for any services furnished to me. Iauthorize any holder of medical information about me to release to the CMS (and its agents) any informationto determine these benefits payable for related services. This information will be used for the purpose ofevaluating and administering claims of benefits.• DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – The guarantor is responsible forpayment of services rendered. The Mount Sinai School of Medicine Department of Neurology cannot beinvolved with separation or divorce disputes.You are responsible for the timely payment of your account. Our financial staff will work closely with youand your carrier to avoid sending any account to an outside agency to collect payment. We reserve to senddelinquent accounts to an outside collection agency.We accept CASH, CHECKS, MASTERCARD, VISA, or AMERICAN EXPRESS CARDS and DISCOVER CARDS.THANK YOU for taking the time to review our policies. Please feel free to ask any questions or share with usspecial concerns.Patient Name: Patient Signature: Date of Birth:Patient Address: City, State: Zip:Today’s Date:Appointment Date:Personal Representative Name:Personal RepresentativeAuthority:Responsible Party Signature:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACYPRACTICES (NOPP)By signing below, I acknowledge that I have been provided a copy of this Notice ofPrivacy Practices and have therefore been advised of how health information about memay be used and disclosed by the hospitals and the facilities listed at the beginning ofthis notice and how I may obtain access to and control this informationPatient Name: Date of Birth: Patient Signature:Today’s Date:Appointment Date:Personal Representative Name:Personal RepresentativeAuthority:Responsible Party Signature:I was not able to obtain the patient’s acknowledgement of receipt of the NOPPupon registration because:• The patient refused to sign despite good faith efforts• The patient was unaccompanied and not alert and oriented• The patient was unaccompanied and needed emergency care• Other, (explain): _________________________________________Employee Signature: _________________ Employee Title: _________________Print Name: _________________________________ Date: ____________________Acknowledgement subsequently obtained, (see above).MR-205

CONSENT FOR COMMUNICATION VIA E-MAIL (Provider-Patient)I,Patient’s last name:E-mail Address:, hereby consent to have my physician,Physician name:, communicate with me or members of his staff, where appropriate or otherphysicians, nurse practitioners and pharmacists via e-mail regarding thefollowing aspects of my medical care and treatment: [test results,prescriptions, appointments, billing, etc.]. I understand that e-mailis not a confidential method of communication. I further understand thatthere is a risk that e-mails communications between my physician and me ormembers of my physician’s office staff or between my physician and otherphysicians, nurse practitioners and pharmacists regarding my medical careand treatment may be intercepted by third parties or transmitted tounintended parties. I also understand that any e-mail communications betweenmy physician and me or members of his office staff or between my physicianand other physicians, nurse practitioners or pharmacists regarding mymedical care and treatment will be printed out and made a part of my medicalrecord. I understand that in an urgent or emergent situation I should callmy provider or go to the Emergency Room and not rely on e-mail.First:Patient Name:Patient Signature:Today’s Date:Appointment Date:Personal Representative Name: Personal Representative Authority: Responsible Party Signature:MR-240 (9/03)

MOUNT SINAI USE OF INFORMATION AUTHORIZATIONDear Patient,Like other major academic medical centers, Mount Sinai depends greatly uponthe generosity of our patients to help us provide the finest in patient care,Educate the next generation of physicians, and promote research and discoveryof new treatments and cures.Federal law now requires hospitals to obtain your written authorization prior toinforming you of educational programs and philanthropic initiatives thatsupport the work of your doctors. Your authorization below permits MountSinai doctors, development officers, trustees, and other staff to learn thename(s) of your health care provider(s) for the purpose of contacting you abouteducational and philanthropic efforts that may be of interest to you.No other information about you or your medical treatment will be disclosed –that is strictly between you and your doctor. Maintaining patientconfidentiality and ensuring your right to privacy has always been, and willalways be, a priority at Mount Sinai.We hope you will take a moment to read this authorization and sign below. Ifyou have any questions, please call the Compliance Officer in the Mount SinaiDevelopment Office at (212) 373-4967.Thank you.I authorize that the Mount Sinai Hospital and Mount Sinai School of Medicine(“Mount Sinai”) may disclose the name of my health care provider(s) to Mount Sinaidevelopment officers, and other staff, volunteers, and consultants and contractorsassisting in fund raising efforts, for the purpose of contacting me about Mount Sinaieducational efforts (e.g., lectures, informational newsletters) and fund raisingopportunities. I understand that this authorization will expire five (5) years from thedate of my signature below. I also understand that my health care treatment atMount Sinai will not be affected in any way by my refusal or failure to sign thisform. I further understand that this authorized information will not be released toany third party vendors for any purpose other than that expressed above. I mayrevoke this authorization at any time by writing to the Mount Sinai DevelopmentOffice, One Gustave L. Levy Place, Box 1049, New York, New York 10029-6574. Bysigning below, I acknowledge that I have read and accept all of the above.Patient Name:Patient Signature:Today’s Date:Appointment Date:Personal Representative Name: Personal Representative Authority: Responsible Party Signature:The patient, or personal representative/guardian, must be provided with a copy of this form after it has been signed.MR-212 (APP3/25/03)

PATIENT'MEDICAL'HISTORY'QUESTIONNAIRE'Kindly#complete#this#form#in#order#to#provide#you#with#the#best#possible#care.Patient’s last name: First: Date:What is the reason for this visit?VbfgjhgfjhyGeneral'(weight'change,'fatigue,'fever,'loss'of'appetite)Heart'disease'(heart'attack,'congestive'heart'failure,'angina,'irregular'heartbeat/arrhythmia)High'blood'pressure'or'low'blood'pressureLung'disease,'including'asthma,'emphysema'or'shortness'of'breath Yes No Yes No Yes No Yes No(Please&specify)(Please&specify)(Please&specify)(Please&specify)Blood'disorder'(including'problems'with'bleeding,'clotting'or'easy'bruising) Yes No(Please&specify)Diabetes'or'low'blood'sugar Yes No (Please&specify)Thyroid'disease Yes No (Please&specify)Stroke Yes No (Please&specify)Neurologic'disorder'(e.g.,'seizure,'frequent'headache,'dizziness,'fainting) Yes No(Please&specify)Psychological/psychiatric'disorder Yes No (Please&specify)Gastrointestinal'problems'(including'ulcer,'diverticulitis,'spastic'colon','bleeding'from'rectum) Yes No(Please&specify)Liver'Disease Yes No (Please&specify)Kidney'or'bladder'disease Yes No (Please&specify)Frequent'infection'(including'pneumonia,'bronchitis,'urinary'tract'infection) Yes No(Please&specify)Eye'problems'or'diseases'(e.g.'glaucoma,'cataract)Arthritis,'muscle,'bone'disorder'(including'fracture) Yes No Yes No(Please&specify)(Please&specify)Immune'system'disorder(including'lupus,'HIV,'AIDS) Yes No(Please&specify)History'of'cancer Yes No (Please&specify)Skin'disorder'(including'hives,'rash,'swelling)Anesthetic'complications'(include'dental'anesthesia) Yes No Yes No(Please&specify)(Please&specify)Other Yes No (Please&specify)

Do'you'have'a'history'of'alcohol'use?If&YES,&how&much&did/do&you&drink? Yes NoHow&often?Do'you'have'a'history'of'smoking?If&&YES,&how&much&did/do&you&smoke? Yes NoHow&often?Do'you'have'a'history'or'drug'abuse?If&&YES,&how&much&did/do&you&use? Yes NoHow&often?Family'History'Are&there&any&conditions&or&diseases&related&to&your&complaint&that&run&in&your&family?&&&& Yes No(Please&specify)Surgical'History'Have&you&had&any&type&of&surgery&(e.g.,&heart,&abdominal,&orthopedic,&oral,&eye,&transplant)?& Yes No(Please&specify)Allergy'History'Have&you&ever&had&a&severe&allergic&reaction&(e.g.,&bee&stings,&food&{milk,&nuts}?&&' Yes No(Please&specify)Have&you&ever&had&an&allergic&reaction&to&any&medications&(antibiotics,&Codeine,&etc)?& Yes No(Please&specify)Medication'History'Please&list&all&medications&you&are&now&taking.&How&much/how&often?Immunizations:''Pneumovax&(pneumonia&Vaccine) Yes NoDate:Influenza&(“Seasonal&Flu&Shot”)& Yes No Date:Patient Name:Patient Signature:Date:Physician Name:Physician Signature:Date:

The Mount Sinai HospitalMount Sinai School of MedicineNOTICE OF PRIVACY PRACTICESEffective Date: April 14, 2003IntroductionTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BEUSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.The Mount Sinai Hospital (MSH), which includes The Mount Sinai Hospital of Queens(MSHQ), Mount Sinai School of Medicine (MSSM), including its owned physician practices(Faculty Practice Associates or FPA and Northshore Medical Group or NSMG) and The MountSinai Diagnostic and Treatment Center (D&TC) (together, “Mount Sinai” for purposes of thisnotice) are required by law to protect the privacy of health information that may reveal youridentity. Mount Sinai is also required to provide you with a copy of this notice which describesthe health information privacy practices of its medical staff, and affiliated health care providersthat jointly provide health care services with the institution, and to follow the terms of the noticethat is currently in effect.A copy of our current notice will always be posted in our reception area. You will also be ableto obtain your own copies by accessing our website at http://www.mssm.edu/HIPAA, calling ouroffice or asking for one at the time of your next visit.MSH and D&TC – 212-241-4669MSSM FPA – 212-241-7715MSHQ – 718-267-4220NSMG – 631-367-5125If you have any questions about this notice or would like further information, please contact ourPrivacy Officer at the relevant telephone number above.MR-250 (Rev 5/04).

PARTICIPANTSMount Sinai provides health care to patients jointly with physicians and other health careprofessionals and organizations. The privacy practices described in this notice will be followedby:• Any health care professional who treats you at any of our locations;• All employees, medical staff, trainees, students or volunteers at any of our locations;• Any business associates of the institution (which are described further below)These practices will be followed at all of our sites:Main Manhattan campus, The Mount Sinai Hospital of Queens, Mount Sinai School of Medicine(MSSM) including the Faculty Practice Associates. Off-site locations that are part of theseinstitutions will follow this notice as well. A list of current locations is attached. (Attachment E).These facilities and individuals will share protected health information with each other, asnecessary to carry out the treatment, payment, and healthcare operations described in this notice.IMPORTANT SUMMARY INFORMATIONWhat Health Information is Protected. We are committed to protecting the privacy ofinformation we gather about you while providing health-related services. Some examples ofprotected health information are: information indicating that you are a patient at Mount Sinai orreceiving treatment or other health-related services from our institution; information about yourhealth condition (such as a disease that you may have); information about health care products orservices you have received or may receive in the future (such as an operation); or informationabout your health care benefits under an insurance plan (such as whether a prescription iscovered); when combined with: demographic information (such as your name, address, orinsurance status); unique numbers that may identify you (such as your social security number,your phone number or your driver’s license number);; and other types of information that mayidentify who you are.Personal Representatives. If a person has the authority under law to make decisions for yourelative to Healthcare (“personal representative”) Mount Sinai will treat your personalrepresentative the same way we would treat you with respect to your PHI. Parents and guardianswill generally be personal representatives of minors unless the minors are permitted by law to acton their own behalf.Requirement for Written Authorization. We will obtain your written authorization beforeusing your health information or sharing it with others outside Mount Sinai, except as describedbelow. You may also initiate the transfer of your records to another person by completing awritten authorization form. If you provide us with written authorization, you may revoke thatwritten authorization at any time, except to the extent that we have already relied upon it. Torevoke a written authorization, please write to:MSH and D&TC – Privacy Officer, Box 1109, One Gustave L. Levy Place, New York, NY10029MR-250 (Rev 5/04)2

MSSM FPA - Patient Rights Coordinator, Box 1621, One Gustave L. Levy Place,New York, NY 10029MSHQ – Privacy Officer, 25-10 30 th Avenue, Long Island City, NY 11202NSMG – Privacy Officer, 325 Park Avenue, Huntington, NY 11743Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and GeneticInformation. Special privacy protections apply to HIV-related information, alcohol andsubstance abuse treatment information, mental health information, and genetic information.Some parts of this general Notice of Privacy Practices may not apply to these types ofinformation. Notices explaining how these categories of information will be protected by MountSinai are attached as Attachments A-D.YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATIONYou have the following rights regarding your medical information:Right To Inspect and Copy RecordsYou have the right to inspect and obtain a copy of any of your health information that may beused to make decisions about you and your treatment for as long as we maintain this informationin our records. This includes medical and billing records. To inspect or obtain a copy of yourhealth information, please submit your request in writing to:MSH and D&TC - Medical Record Department, Box 1111MSSM FPA - Patient Rights Coordinator, Box 1621MSHQ - Medical Record DepartmentNSMG – Medical Records DepartmentIf you request a copy of the information, we may charge a fee, as permitted by law, for the costsof copying, mailing or other supplies we use to fulfill your request. The fee must generally bepaid before or at the time we give the copies to you.We will respond to your request for inspection of records within 10 days. We ordinarily willrespond to requests for copies within 30 days if the information is located in our facility andwithin 60 days if it is located off-site at another facility. If we need additional time to respond toa request for copies, we will notify you in writing within the time frame above to explain thereason for the delay and when you can expect to have a final answer to your request.Under certain very limited circumstances, we may deny your request to inspect or obtain a copyof your information. If we do, we will provide you with a summary of the information instead.We will also provide a written statement that explains the reasons for providing only a summaryand a complete description of your rights to have that decision reviewed and how you canexercise those rights. The notice will also include information on how to file a complaint aboutthese issues with us or with the Secretary of the Department of Health and Human Services. Ifwe have reason to deny only part of your request, we will provide complete access to theremaining parts after excluding the information we may not let you inspect or copy.MR-250 (Rev 5/04)3

Right To Amend RecordsIf you believe that the health information we have about you is incorrect or incomplete, you mayask us to amend the information. You have the right to request an amendment for as long as theinformation is kept in our records. To request an amendment, please write toMSH and D&TC - Medical Records, Box 1111MSSM FPA - Patient Rights Coordinator, Box 1621MSHQ - Medical RecordsNSMG – Medical Records DepartmentYour request should include the reasons why you think we should make the amendment.Ordinarily we will respond to your request within 60 days. If we need additional time torespond, we will notify you in writing within 60 days to explain the reason for the delay andwhen you can expect to have a final answer to your request.If we deny part or all of your request, we will provide a written notice that explains our reasonsfor doing so. You will have the right to have certain information related to your requestedamendment included in your records. For example, if you disagree with our decision, you willhave an opportunity to submit a statement explaining your disagreement which we will includein your records. We will also include information on how to file a complaint with us or with theSecretary of the Department of Health and Human Services. These procedures will be explainedin more detail in any written denial notice we send you.Right To an Accounting of DisclosuresAfter April 14, 2003, you have a right to request an “accounting of disclosures” which is a listwith information about how the institution has shared your information with others outsideMount Sinai.An accounting list will not include:Disclosures we made to you or your personal representative;Disclosures we made pursuant to your written authorization;Disclosures we made for treatment, payment or business operations;Disclosures made from the patient directory;Disclosures made to your friends and family involved in your care or payment for yourcare;Disclosures that were incidental to permissible uses and disclosures of your healthinformation (for example, when information is overheard by another patient passing by);Disclosures for purposes of research, public health or our business operations of limitedportions of your health information that do not directly identify you;Disclosures made to federal officials for national security and intelligence activities;Disclosures about inmates to correctional institutions or law enforcement officers;Disclosures made before April 14, 2003.MR-250 (Rev 5/04)4

To request this list, please write to:MSH and D&TC – Medical Records, Box 1111MSSM FPA - Patient Rights Coordinator, Box 1621MSHQ – Medical Records DepartmentNSMG – Privacy OfficerYour request must state a time period within the past six years (but after April 14, 2003) forthe disclosures you want us to include. For example, you may request a list of the disclosuresthat we made between January 1, 2004 and January 1, 2005. You have a right to receive one listwithin every 12 month period for free. However, we may charge you for the cost of providingany additional lists in that same 12 month period. We will always notify you of any costinvolved so that you may choose to withdraw or modify your request before any costs areincurred.Ordinarily we will respond to your request for an accounting within 60 days. If we needadditional time to prepare the accounting list you have requested, we will notify you in writingabout the reason for the delay and the date when you can expect to receive the accounting list. Inrare cases, we may have to delay providing you with the accounting list without notifying youbecause a law enforcement official or government agency has directed us to do so.Right To Request Additional Privacy ProtectionsYou have the right to request that we further restrict the way we use and disclose your healthinformation to treat your condition, collect payment for that treatment, or run our businessoperations. You may also request that we limit how we disclose information about you to familyor friends involved in your care. For example, you could request that we not discloseinformation about a surgery you had. To request restrictions, please write to:MSH and D&TC – Medical Records Department, Box 1111MSSM FPA – Patient Rights Coordinator, Box 1621MSHQ – Privacy OfficerNSMG – Privacy OfficerYour request should include (1) what information you want to limit; (2) whether you want tolimit how we use the information, how we share it with others, or both; and (3) to whom youwant the limits to apply.We are not required to agree to your request for a restriction, and in some cases the restrictionyou request may not be permitted under law. However, if we do agree, we will be bound by ouragreement unless the information is needed to provide you with emergency treatment or tocomply with the law. Once we have agreed to a restriction, you have the right to revoke therestriction at any time. Under some circumstances, we will also have the right to revoke therestriction as long as we notify you before doing so; in other cases, we will need your permissionbefore we may revoke the restriction.MR-250 (Rev 5/04)5

Right To Request Confidential CommunicationsYou have the right to request that we communicate with you about your medical matters in amore confidential way by requesting that we communicate with you by alternative means or atalternative locations. For example, you may ask that we contact you at home instead of at work.To request more confidential communications, please write toMSH and D&TC- Privacy Officer, Box 1109MSSM FPA - Patient Rights Coordinator, Box 1621MSHQ - Privacy OfficerNSMG – Privacy OfficerWe will not ask you the reason for your request, and we will try to accommodate allreasonable requests. Please specify in your request how or where you wish to be contacted, andhow payment for your health care will be handled if we communicate with you through thisalternative method or location.How to Obtain a Copy of Revised Notice. We may change our privacy practices from time totime. If we do, we will revise this notice so you will have an accurate summary of our practices.The revised notice will apply to all of your health information. We will post any revised noticein our hospital reception area. You will also be able to obtain your own copy of the revisednotice by accessing our website at http://www.mssm.edu/HIPAA, calling our office atMSH and D&TC – 212-241-4669MSSM FPA – 212-241-7715MSHQ – 718-267-4220NSMG – 631-367-5125or asking for one at the time of your next visit. The effective date of the notice will always benoted in the top right corner of the first page. We are required to abide by the terms of the noticethat is currently in effect.MR-250 (Rev 5/04)6

How to File a Complaint. If you believe your privacy rights have been violated, you may file acomplaint with The Mount Sinai Hospital (MSH), The Mount Sinai Hospital of Queens(MSHQ), or Mount Sinai School of Medicine (MSSM) including its owned physician practices(Faculty Practice Associates or FPA) or with the Secretary of the Department of Health andHuman Services. To file a complaint please contact:MSH and D&TC Privacy Officer - (212) 241-4669MSSM FPA Patient Rights Coordinator - (212) 241- 7715MSHQ Privacy Officer – (718) 267-4220NSMG Privacy Officer – (631) 367-5125OrDepartment of Health and Human Services/Office of Civil Rights at:www.hhs.gov/ocr/hipaaNo one will retaliate or take action against you for filing a complaint.HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATIONWITHOUT YOUR WRITTEN AUTHORIZATIONTreatment. We may share your health information with healthcare providers at Mount Sinaiwho are involved in taking care of you, and they may in turn use that information to diagnose ortreat you. A healthcare provider at Mount Sinai may share your health information with anotherhealthcare provider for your diagnosis and treatment.Payment. We may use your health information or share it with others so that we may obtainpayment for your health care services. For example, we may share information about you withyour health insurance company in order to obtain reimbursement after we have treated you, or todetermine whether it will cover your treatment. We might also need to inform your healthinsurance company about your health condition in order to obtain pre-approval for yourtreatment, such as admitting you to the hospital for a particular type of surgery. Finally, we mayshare your information with other health care providers, payors and their business associates fortheir payment activities.Business Operations. We may use your health information or share it with others in order toconduct our business operations. For example, we may use your health information to evaluatethe performance of our staff in caring for you, to educate our staff on how to improve the carethey provide for you or to conduct training programs for students, trainees and other healthcarepractitioners. Finally, we may share your health information with other health care providers andpayors for certain of their business operations if the information is related to a relationship theprovider or payor currently has or previously had with you, and if the provider or payor isrequired by federal law to protect the privacy of your health information.MR-250 (Rev 5/04)7

Appointment Reminders, Treatment Alternatives, Benefits and Services. In the course ofproviding treatment to you, we may use your health information to contact you with a reminderthat you have an appointment for treatment or services at our facility. We may also use yourhealth information in order to recommend possible treatment alternatives or health-relatedbenefits and services that may be of interest to you.Fundraising. To support our business operations, we may use only demographic informationabout you, including information about your age and gender, where you live or work, and thedates that you received treatment, in order to contact you to raise money to help us operate. Wemay also share this information with a charitable foundation that will contact you to raise moneyon our behalf.Business Associates. We may disclose your health information to contractors, agents and otherbusiness associates who need the information in order to assist us with obtaining payment orcarrying out our business operations. For example, we may share your health information with abilling company that helps us to obtain payment from your insurance company. Anotherexample is that we may share your health information with an insurance company or law firm, ora risk management organization in order to obtain professional advice about how to manage riskand legal liability, including insurance or legal claims. We may also share your healthinformation with an accounting firm in order to obtain advice on legal compliance. If we dodisclose your health information to a business associate, we will have a written contract to ensurethat our business associate also protects the privacy of your health information.Patient Directory. If you do not object, we will include your name, your location in our facility,your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation in our PatientDirectory while you are a patient at Mount Sinai or one of the facilities listed at the beginning ofthis notice. This directory information, except for your religious affiliation, may be released topeople who ask for you by name. Your religious affiliation may be given to a member of theclergy, such as a priest or rabbi, even if he or she doesn’t ask for you by name. If you wish toopt out or restrict access please inform the Business Associate at registration or your nurse.Family and Friends Involved in Your Care. If you do not object, we may share your healthinformation with a family member, relative, or close personal friend who is involved in your careor payment for that care. In some cases, we may need to share your information with a disasterrelief organization that will help us notify these persons.As Required By Law. We may use or disclose your health information if we are required bylaw to do so. We also will notify you of these uses and disclosures if notice is required by law.MR-250 (Rev 5/04)8

Public Health Activities. We may disclose your health information to authorized public healthofficials (or a foreign government agency collaborating with such officials) so they may carryout their public health activities. For example, we may share your health information withgovernment officials that are responsible for controlling disease, injury or disability. We mayalso disclose your health information to a person who may have been exposed to acommunicable disease or be at risk for contracting or spreading the disease if a law permits us todo so. And finally, we may release some health information about you to your employer if youremployer hires us to provide you with a physical exam and we discover that you have a workrelatedinjury or disease that your employer must know about in order to comply withemployment laws.Victims of Abuse, Neglect or Domestic Violence. We may release your health information to apublic health authority that is authorized to receive reports of abuse, neglect or domesticviolence. For example, we may report your information to government officials if we reasonablybelieve that you have been a victim of such abuse, neglect or domestic violence. We will makeevery effort to obtain your permission before releasing this information, but in some cases wemay be required or authorized to act without your permission.Health Oversight Activities. We may release your health information to government agenciesauthorized to conduct audits, investigations, and inspections of our facility. These governmentagencies monitor the operation of the health care system, government benefit programs such asMedicare and Medicaid, and compliance with government regulatory programs and civil rightslaws.Product Monitoring, Repair and Recall. We may disclose your health information to a personor company that is regulated by the Food and Drug Administration for the purpose of: (1)reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defectiveor dangerous products; or (3) monitoring the performance of a product after it has been approvedfor use by the general public.Lawsuits and Disputes. We may disclose your health information if we are ordered to do so bya court or administrative tribunal that is handling a lawsuit or other dispute.Law Enforcement. We may disclose your health information to law enforcement officials forthe following reasons:To comply with court orders or laws that we are required to follow;To assist law enforcement officers with identifying or locating a suspect, fugitive,witness, or missing person;If you have been the victim of a crime and we determine that: (1) we have been unable toobtain your agreement because of an emergency or your incapacity; (2) law enforcementofficials need this information immediately to carry out their law enforcement duties; and(3) in our professional judgment disclosure to these officers is in your best interests;If we suspect that death resulted from criminal conduct;If necessary to report a crime that occurred on our property; orIf necessary to report a crime discovered during an offsite medical emergency (forexample, by emergency medical technicians at the scene of a crime).MR-250 (Rev 5/04)9

To Avert A Serious And Imminent Threat to Health or Safety. We may use your healthinformation or share it with others when necessary to prevent a serious and imminent threat toyour health or safety, or the health or safety of another person or the public. In such cases, wewill only share your information with someone able to help prevent the threat. We may alsodisclose your health information to law enforcement officers if you tell us that you participatedin a violent crime that may have caused serious physical harm to another person (unless youadmitted that fact while in counseling), if we determine that you escaped from lawful custody(such as a prison) or eloped from a mental health institution.National Security and Intelligence Activities Or Protective Services. We may disclose yourhealth information to authorized federal officials who are conducting national security andintelligence activities or providing protective services to the President or other importantofficials.Military and Veterans. If you are in the Armed Forces, we may disclose health informationabout you to appropriate military command authorities for activities they deem necessary tocarry out their military mission. We may also release health information about foreign militarypersonnel to the appropriate foreign military authority.Inmates and Correctional Institutions. If you are an inmate or you are detained by a lawenforcement officer, we may disclose your health information to the prison officers or lawenforcement officers if necessary to provide you with health care, or to maintain safety, securityand good order at the place where you are confined. This includes sharing information that isnecessary to protect the health and safety of other inmates or persons involved in supervising ortransporting inmates.Workers’ Compensation. We may disclose your health information for workers’ compensationor similar programs that provide benefits for work-related injuries.Coroners, Medical Examiners and Funeral Directors. We may use health information toidentify a deceased person or determine the cause of death or disclose health information to acoroner or medical examiner for such purposes. We may also release this information to funeraldirectors as necessary to carry out their duties.Organ and Tissue Donation. If you are a potential organ donor, we may use your healthinformation or disclose your health information to other organizations that procure or storeorgans, eyes or other tissues for the purpose of investigating whether donation or transplantationis possible under applicable laws.MR-250 (Rev 5/04)10

Research. In most cases, we will ask for your written authorization before using your healthinformation or sharing it with others in order to conduct research. However, under somecircumstances, we may use and disclose your health information without your writtenauthorization if Mount Sinai School of Medicine’s Institutional Review Board (IRB), applyingspecific criteria, determines that the particular research protocol poses minimal risk to yourprivacy. Under no circumstances, however, would we allow researchers to use your name oridentity publicly. We may also release your health information without your writtenauthorization to people who are preparing a future research project, so long as any informationidentifying you does not leave our facility. We may share health information with people whoare conducting research using the information of deceased persons, as long as they agree not toremove from our facility any information that identifies the deceased person.Completely De-identified or Partially De-identified Information.We may use and disclose your health information if we have removed any information that hasthe potential to identify you so that the health information is “completely de-identified.” Wemay also use and disclose “partially de-identified” health information about you for research,public health and specific healthcare operations if the person who will receive the informationsigns an agreement to protect the privacy of the information as required by federal and state law.Partially de-identified health information will exclude all direct identifiers but may include zipcode, dates of birth, admission and discharge.Incidental DisclosuresWhile we will take reasonable steps to safeguard the privacy of your health information, certaindisclosures of your health information may occur during or as an unavoidable result of ourotherwise permissible uses or disclosures of your health information. For example, during thecourse of a treatment session, other patients in the treatment area may see, or overhear discussionof, your health information.MR-250 (Rev 5/04)11

Attachment ACONFIDENTIALITY OF HIV-RELATED INFORMATIONEffective Date: April 14, 2003The privacy and confidentiality of HIV-related information maintained by Mount Sinai isprotected by Federal and State law and regulations. These protections go above and beyond theprotections described in Mount Sinai’s general Notice of Privacy Practices (NOPP). If you havequestions about this notice or would like further information, please contact:The Mount Sinai Hospital and Diagnostic and Treatment Center Privacy Officer at212 - 241-4669Mount Sinai School of Medicine FPA Patient Rights Coordinator at 212-241-7715The Mount Sinai Hospital of Queens Privacy Officer at 718 267-4220Northshore Medical Group Privacy Officer at 631-367-5125We recommend that you also take time to review the Mount Sinai Notice of Privacy Practices forinformation about how your health information may generally be used and disclosed by MountSinai. The Mount Sinai Notice of Privacy Practices also provides information about how youmay obtain access to your health information, including confidential HIV-related information. Ifthere is any conflict between the Notice of Privacy Practices and this notice, the protectionsdescribed in this notice will apply instead of the protections described in the NOPP.Confidential HIV-related information is any information indicating that you had an HIV-relatedtest, have HIV-related illness or AIDS, or have an HIV-related infection, as well as anyinformation which could reasonably identify you as a person who has had a test or has HIVinfection.Under New York State law, confidential HIV-related information may only be given to personsallowed to have it by law, or persons you have allowed to have it by signing a writtenauthorization form.Confidential HIV-related information about you may be used by personnel within Mount Sinaiwho need the information to provide you with direct care or treatment, to process billing orreimbursement records, or to monitor or evaluate the quality of care provided at the hospital.Generally Mount Sinai may not reveal to an outside person confidential HIV-related informationthat the institution obtains in the course of treating you, unless:Mount Sinai obtains your written authorization;The disclosure is to a person who is authorized to make health care decisions onyour behalf and the information disclosed is needed by that person to makehis/her decisions;The disclosure is to another health care provider or payer for treatment orpayment purposes;MR-250 (Rev 5/04)12

• The disclosure is to a third party of the institution who needs the information toprovide you with direct care or treatment, to process billing or reimbursementrecords, or to monitor or evaluate the quality of care provided at Mount Sinai. Insuch cases, Mount Sinai will have an agreement with the third party to ensure thatyour confidential HIV-related information is protected as required under Federaland State confidentiality laws and regulations;The disclosure is required by law or court order;The disclosure is to an organization that procures body parts for transplantation;You receive services under a program monitored or supervised by a Federal, Stateor local government agency and the disclosure is made to such governmentagency or other employee or agent of the agency when reasonably necessary forthe supervision, monitoring, administration of provision of the program’sservices;Mount Sinai is required under Federal or State law to make the disclosure to ahealth officer;The disclosure is required for public health purposes;You are an inmate at a correctional facility and disclosure of confidential HIVrelatedinformation to the medical director of such facility is necessary for thedirector to carry out his or her functions;The patient is deceased and the disclosure is made to a funeral director who hastaken charge of the deceased person’s remains and who has access in the ordinarycourse of business to confidential HIV-related information on the deceasedperson’s death certificate;;The disclosure is made to report child abuse or neglect to appropriate State orlocal authorities.Violation of these privacy regulations may subject the institution to civil or criminal penalties.Suspected violations may be reported to appropriate authorities in accordance with Federal andState law. To file a complaint mail completed form DOH-2865 (Complaint Report for AllegedViolation of Article 27-F) to:NYS Department of Health/AIDS Institute/Special Investigation Unit5 Penn PlazaNew York, New York 10001Please refer to Mount Sinai's main Notice of Privacy Practices for additional information.MR-250 (Rev 5/04)13

MOUNT SINAIATTACHMENT BCONFIDENTIALITY OF ALCOHOL AND SUBSTANCE ABUSE TREATMENTINFORMATIONEffective Date: April 14, 2003The confidentiality of alcohol and substance abuse treatment records maintained by Mount Sinaiis protected by Federal and State law and regulations. These protections go above and beyondthe protections described in the Mount Sinai Notice of Privacy Practices. If you have questionsabout this notice or would like further information, please contact:The Mount Sinai Hospital and Diagnostic and Treatment Center Privacy Officer at 212-241-4669The Mount Sinai School of Medicine FPA Patient Rights Coordinator at 212-241-7715The Mount Sinai Hospital of Queens Privacy Officer at (718) 267-4220Northshore Medical Group Privacy Officer at 631- 367-5125We recommend that you take time to review the Mount Sinai Notice of Privacy Practices forinformation about how your health information may generally be used and disclosed by MountSinai. The Mount Sinai Notice of Privacy Practices provides information about how you mayobtain access to your health information, including alcohol and substance abuse treatmentrecords. If there is any conflict between the Notice of Privacy Practices and this notice, theprotections described in this notice will apply instead of the protections described in the Noticeof Privacy Practices.CONFIDENTIALITY OF ALCOHOL AND SUBSTANCE ABUSE TREATMENTINFORMATIONConfidential alcohol and substance abuse treatment records include any information thatidentifies you as having been diagnosed with, treated for or referred for treatment of alcoholabuse, substance abuse or chemical dependency.Information about you may be used by personnel within Mount Sinai in connection with theirduties to provide you with diagnosis of, treatment for or referral for treatment of alcohol orsubstance abuse. Such use will be limited to the minimum amount of information necessary tocarry out their duties. Generally Mount Sinai may not reveal to a person outside of Mount Sinaiany information that would identify you as under treatment for alcohol or substance abuse,unless:MR-250 (Rev 5/04)14

Your written authorization is obtained;The disclosure is allowed by a court order and permitted under Federal and Stateconfidentiality laws and regulations;The disclosure is made to medical personnel in a medical emergency;The disclosure is made to qualified researchers without your written authorizationwhen such research poses minimal risk to your privacy. When required by law,we will obtain an agreement from the researcher to protect the privacy andconfidentiality of your information;The disclosure is made to a qualified service organization that performs certaintreatment services (such as lab analyses) or business operations (such as billcollection) for Mount Sinai. Mount Sinai will obtain the qualified serviceorganization’s agreement in writing to protect the privacy and confidentiality ofyour information in accordance with Federal and State law;The disclosure is made to a government agency or other qualified nongovernmentpersonnel to perform an audit or evaluation of Mount Sinai. MountSinai will obtain an agreement in writing from any non-government personnel toprotect the privacy and confidentiality of your information in accordance withFederal and State law;The disclosure is made to report a crime committed by a patient either at MountSinai or against any person who works for Mount Sinai or about any threat tocommit such a crime; orThe disclosure is made to report child abuse or neglect to appropriate State orLocal authorities.Violation of these privacy regulations is a crime. Suspected violations may be reported toappropriate authorities in accordance with Federal and State law.Please refer to Mount Sinai's main Notice of Privacy Practices for additional information.MR-250 (Rev 5/04)15

MOUNT SINAIATTACHMENT CCONFIDENTIALITY OF MENTAL HEALTH INFORMATIONAND PSYCHOTHERAPY NOTESEffective Date: April 14, 2003The privacy and confidentiality of mental health information and psychotherapy notesmaintained by Mount Sinai is protected by Federal and State law and regulations. Theseprotections go above and beyond the protections described in the Mount Sinai Notice of PrivacyPractices. If you have questions about this notice or would like further information, pleasecontact:The Mount Sinai Hospital and Diagnostic and Treatment Center Privacy Officer at (212)241-4669The Mount Sinai School of Medicine FPA Patient Rights Coordinator at (212) 241-7715The Mount Sinai Hospital of Queens Privacy Officer at (718) 267-4220Northshore Medical Group Privacy Officer at (631) 367-5125We recommend that you also take time to review the Mount Sinai Notice of Privacy Practices forinformation about how your health information may generally be used and disclosed by MountSinai. The Notice of Privacy Practices also provides information about how you may obtainaccess to your health information, including mental health information. If there is any conflictbetween the Notice of Privacy Practices and this notice, the protections described in this noticewill apply instead of the protections described in the Notice of Privacy Practices.CONFIDENTIALITY OF MENTAL HEALTH INFORMATIONMental health information about you may be used by personnel within Mount Sinai (or itsBusiness Associates) in connection with their duties to provide you with treatment, obtainpayment for that treatment, or conduct Mount Sinai’s business operations. Generally MountSinai may not reveal mental health information about you to other persons outside of MountSinai, except in the following situations:When Mount Sinai has obtained your written authorization;To a personal representative who is authorized to make health care decisions on yourbehalf;To government agencies or private insurance companies in order to obtain payment forservices we provided to you;To comply with a court order;To appropriate persons who are able to avert a serious and imminent threat to the healthor safety of you or another person;MR-250 (Rev 5/04)16

To appropriate government authorities to locate a missing person or conduct a criminalinvestigation as permitted under Federal and State confidentiality laws;To other licensed hospital emergency services as permitted under Federal and Stateconfidentiality laws;To the mental hygiene legal service offered by the State;To attorneys representing patients in an involuntary hospitalization proceeding;To authorized government officials for the purpose of monitoring or evaluating thequality of care provided by the hospital or its staff;To qualified researchers without your specific authorization when such research posesminimal risk to your privacy;To coroners and medical examiners to determine cause of death; andIf you are an inmate, to a correctional facility which certifies that the information isnecessary in order to provide you with health care, or in order to protect the health orsafety of you or any other persons at the correctional facility.CONFIDENTIALITY OF PSYCHOTHERAPY NOTESPsychotherapy notes are notes by a mental health professional that document or analyze thecontents of a conversation during a private counseling session – or during a group, joint, orfamily counseling session. If these notes are maintained separately from the rest of your medicalrecords, they can only be used and disclosed as follows.In general, Psychotherapy notes may not be used or disclosed without your written authorization,except in the following circumstances.The mental health professional who created the notes may use them to provide you withfurther treatment;The mental health professional who created the notes may disclose them to students,trainees, or practitioners in mental health who are learning under supervision to practiceor improve their skills in group, joint, family, or individual counseling;The mental health professional who created the notes may disclose them as necessary todefend him or herself, or Mount Sinai, in a legal proceeding initiated by you or yourpersonal representative;The mental health professional who created the notes may disclose them as required bylaw;The mental health professional who created the notes may disclose the notes toappropriate government authorities when necessary to avert a serious and imminent threatto the health or safety of you or another person;The mental health professional who created the notes may disclose them to the UnitedStates Department of Health and Human Services when that agency requests them inorder to investigate the mental health professional’s compliance, or Mount Sinai’scompliance, with Federal privacy and confidentiality laws and regulations; andThe mental health professional that created the notes may disclose them to medicalexaminers and coroners if necessary to determine the cause of death.MR-250 (Rev 5/04)17

The mental health professional who created the notes may disclose them to a healthoversight agency for a lawful purpose related to oversight of the mental healthprofessional.All other uses and disclosures of psychotherapy notes require your special written authorization.Please refer to Mount Sinai's main Notice of Privacy Practices for additional information.MR-250 (Rev 5/04)18

MOUNT SINAIATTACHMENT DCONFIDENTIALITY OF GENETIC INFORMATIONEffective Date: April 14, 2003The privacy and confidentiality of genetic information maintained by Mount Sinai is protected by Statelaw and regulations. These protections go above and beyond the protections described in Mount Sinai' sgeneral Notice of Privacy Practices. If you have questions about this notice or would like furtherinformation, please contact:The Mount Sinai Hospital and Diagnostic and Treatment Center Privacy Officer at 212- 241-4669The Mount Sinai School of Medicine FPA Patient Rights Coordinator at 212-241-7715The Mount Sinai Hospital of Queens Privacy Officer at 718- 267-4220Northshore Medical Group Privacy Officer at 631- 367-5125We recommend that you also take time to review Mount Sinai’s Notice of Privacy Practices forinformation about how your health information may generally be used and disclosed by Mount Sinai.Mount Sinai’s Notice of Privacy Practices also provides information about how you may obtain access toyour health information, including confidential genetic informationUnder New York State law, special restrictions apply to (1) genetic testing of human biological samplesand (2) the disclosure of information derived from genetic tests to any person or organization. Genetictest means any laboratory test of DNA, chromosomes, genes or gene products to detect a genetic variationlinked to a predisposition to a genetic disease.Mount Sinai will not perform a genetic test on a biological sample taken from you unless Mount Sinaiobtains your written informed consent under NYS law. With your informed consent, Mount Sinai mayuse the results of your genetic test for treatment, payment and healthcare operations (See NOPP pp. 6-7).Any other uses or disclosures of the results of your genetic test will generally require your writtenauthorization. This authorization is separate from, and may not be combined with the informed consent.Authorization is not required if:The disclosure is to a person who is authorized to make health care decisions on yourbehalf and the information disclosed is needed by that person to make his/her decisions;The disclosure is required or allowed by law or court order.Mount Sinai’s IRB has determined to allow the disclosure of information obtained aboutyou from genetic tests on your stored tissue, or information which links you with specifictest results and you have signed either a Research Authorization form or a Consent toRelease Genetic Information form under NY Civil Rights Law §§ 79-l(3)(a) and 79-l(9)(d)].Violation of these privacy regulations may subject Mount Sinai to civil or criminal penalties. Suspectedviolations may be reported to appropriate authorities in accordance with Federal and State law.Please refer to Mount Sinai’s main Notice of Privacy Practices for additional information.MR-250 (Rev 5/04)19

NOPPATTACHMENT E“Mount Sinai Off-site Locations”I. Mount Sinai Hospital (Manhattan)• Primary Care Building (101 st Street Manhattan)IMAGeriatrics• Adolescent Health Center (94 th Street)• Sports Therapy (59 th Street)• Vocational Therapy (96 th Street)• Psychiatry OPD (1160 Fifth Avenue)• Dialysis (94 th Street)• REAP (Madison Avenue/98 th Street)• School Based Clinics• Northshore Practice• Senior Outreach (5E 102 nd Street)• Visiting Doctors (19 East 101 st Street)II.MSSM FPA• Community Medicine (1391 Madison Avenue)• Community Medicine (Astoria, Queens)• Community Medicine (Yonkers, New York)• WTC Recovery (1200 Fifth Avenue)• Primary Care Building (1470 Madison Avenue)Geriatrics• Primary Care Building (1470 Madison Avenue)General/IMA• Psychiatry (1100 Park Avenue Suite 1B)• Psychiatry (1160 Fifth Avenue, ground Floor, 1 South, 1 North)• Psychiatry (1 West 85 th Street, Suite 1A)• Psychiatry (57-59 East 96 th Street)• West Side PracticeII.Mount Sinai Queens• Senior Health Center• Family Health Associates• Industrial Health CenterIII.Diagnostic and Treatment Center (D&TC)MR-250 (Rev 5/04)20