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07/2.17/A\\. 5/2014 04:15am MSH 4 140 rase vv Mount Sinai Doctors Fax Faculty -V: • Practice Phi, az Pages: its: T. n _pat= 7kV 11"f From.: Dr. talabrizi ntanij Amxette Pub:notary, Critical Care a:_a , Sleep 2viedicine Pho F O u r ge= O For Review O Please Comic n Please Reply El Please Recycle Notes: Prat S-Ci -F A-)1 Q CO ac iftSurarte-e, Card • _Lb Q tat ticifth •(-ctnple-leci -Ryens . The document accompanying this trar.smission contains information that may be confidential or privileged. This information is intended for the use of the individual or entity name above only and use by any other party is not authorized. The authorized recip:er.t of th:s Information 's prohibited from disclosing this information to any other party except as permitted or required by applicable federal, state, local laws, and regulations and must use and maintain the information in accordance with all applicable laws and regulations. If you are not the intended :recipient, you are hereby notified that any disclosure, copying, distribution, cr use of the convent of these document is strictly prohibited. If you have received this information M error, please notify the sender immediately by phone. EFTA00283626 07/25/2014 04:16am DISH 1010..•••••••••••••,...^T WTI?" gl40 rage ULFVV Mount Faculty Practice Sinai Doctors CONSENT FOR COMMUNICATION VIA E-MAIL (Provider-Patient) , hereby consent to have my physician, . , communicate with me or members of his/her staff, where appropriate or other physicians, nurse practitioners pharmacists via e-mail regarding the following aspects of my medical care and treatment: (test results, prescriptions, appointments, billing, etc.]. I understand that e-mai: is not a confidential method of communication. : further understand that there is a risk that e mail communications between my physician and me or members of my physician's office staff or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to' unintended parties. : also understand that any e-mail communicat4cas between my physician and me or members of his/her office staff, or between my physician and other Physicians, nurse practitioners or pharmacists regarding'my medical care and treatment will be printed out.and made a part of mymedical record. I understand that in an urgent or emergent situation I should call my provider or co to the Emergency Room and not rely on e-mail. E-mail: Signature: Date: EFTA00283627 UT/n/2014 U4: lbam hbH #149 Page 03/06 The MourA Sinai Metre) Gently One Gustave t. Low RIR bev•Yarlt. NY 10029-6574 The Mount Saki Hospital MOW Sinai School of Meeteine Mt. Sinai Medical Center Department of Medicine FPA. Practice Patient Responsibility and Assignment of Benefits In consideration of medical care and services rendered to me, I agree that my responsibilities to (provider) of the Department of Medicine include but are not limited to the. following: • Obtaining all necessary referrals from my Primary Care physician for visit(s) to specialists. • Obtaining all necessary pre-authorizations for procedures to be performed by the specialist. • Payment of co-payments and deductibles not paid by my insurance plan. • Payment for services not covered by my insurance plan. • Informing the o5ce of any change in my insurance coverage. Medicare Beneficiaries: • 1 hereby authorize the release of medical and/or other information about me to the Social Security Administration and Health Care Financing Admirdstation or its intermediaries or carriers (including information relating to mental illness and/or AIDS/ARCA-11V) necessary for this or any related Medicare claim. All Patients: • I hereby authorize the release of medical and/or other information about me that is necessary for the processing of my insurance benefits. • I hereby authorize payment on my behalf. • I hereby assign benefits payable to (provider) I have read, Understand and agree with the above. Name of Patient Date Si nature of Patient or Authorized Representative Date Relationship to Patient r%•1/4 Date EFTA00283628 07/25/2014 04:16am hISH Æ47 gent& Facuity Prae:ties RtnRi Doctors {i i ACTC40'itilflGEMETI." OF BP,ar orsorsa OP PRIVACY-PR.4.CrIC.ES • • [NOPP) I abc v ''" signing below, I acicooydtclge*,at I have been provided a copy of this Notis of PØ ?radien and beve therefore berm ad*&d of how health information &bant me mai, be med and disclosed by the hosprals and the facilites Iisted at &..e birirling of tåis note; and bowl tan obtain access to and coutrol tisinforz&n Filistt Name Signa.ture of Patiezt or Personal Rapa-iset:ra-nve , Name of Panett or Persan7.1Represe.ntatve- Date , . • D escrip;d913 pf Personal R.,przsautrgte kl:hor:ty . • I was not able t olatild Miepadent's acknowledgement of receipt of ±e NOPP tepon ruion • The panert re.Ø to signdespri g,otad efforts C The patient was naaccatapar‘M 2-;f3 mat/ and a:~ Q•., The DMinnreis unac- Hnmphnid e 5td em. prify care other (=Leif,: Employee Signatzt EtØloyee "Mit Print NaMe: • , D. ACkhoi;ded~iubsetrc:cedy obcainod;(seeabove). ' [itev 5/04)) EFTA00283629 Uf/2b/2U14 U4: itiam ICH U149 Page Ub/Ut; MOUNT SINAI USE OF INFORMATION AUTHORIZATION Dear Patient, Like other major academic medical centers, Mount Sinai depends greatly upon the generosity of our patients to help us provide the finest in patient care, educate the next generation of physicians, and promote research and discovery of new treatments and cures, •••• Federal law new requires health care providers to obtain your :written . authbrizatoff,prior to contacting you with marketing information or about philanthrochid,initiatives that support the work of your doctors. Your permission for disclosure of your name will allow Mount Sinai stall to contact you about marketing or 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. Maintai-iing patient confidentiality and ensuring your right to privacy has always been, and will always be, a. priority at Mount Sinai. - We hope you will take a mimtent to read this authorization and sign below. If you have any questions, please call the Mount Sinai Development Office at (212) 659-8500. Thank you. I authorize any doctor employed by or on the staff of The Mcrant Sinai Hospital and Mount Sinai School of Medicine (`Mount Sinai") to disclose my name and contact information to Mount Sinai development and public affairs staff for the purpose of contacting me about Mount Sinai marketing and philanthropy opportunities. I understand that my health care treatment at Mount Sinai will not be affected in any way by my refusal or failure to sign this form. Ifurther understand that this authorized information will not be released to any thud parties for any purpose other than that expressed above. This authorization will remain in effect for five years. However, I may revoke this authorization at any time by writing to the Mount Sinai Development Office, One Gustave L. Levy Place, Box 1049, New York New York .10029-6574. By signing below, I acknowledge that /have read and accept all of the above. X x x Signature.of Patient Print Name of Patient Date or Personal RepresentaEve/GuArdian or Personal Representative/Guardian Address of Patient If Applicable, Description of Autherity of Personal Representative/Guardian A sign/4 copy of this form is available upon request by patient orpatient representative MR-212 (REV 4/05) OFFICE USE ONLY EFTA00283630 tlf/ZbiZU I 4 U4:1 tam hbhi #149 Page 06/06 • • " .4.-a• •F • ....ord. rr - %se .es..-••••-•••••nui ' .MOUNT,SINAI HEALTH INFORMATION EXCHANGE AND HEALTHIX CONSENT FORM The Mount Sinai Health irrformation Exchange ('Mount Sinai HIE') and Health& sham Information start people's health electronically end securely to Improve the quality of health care services. This kind of sherihg is called ehealth or heath information technology cHealth17). To learn more about Health IT in New York State, read the brochure, 'Better Information Means Better Care.' You can ask your health am provider for it, or go to the website www.chripfitmnverq. In this Consent Form, you can choose whether to allow the health-care providers listed on the MountSinai HIE webste wwwnitathtalnaiconnactorq nit participants.) to obtain access to your medical records through a computer network operated by the Mount Sinai HIE. This can help collect the medical records you have in different places where you get health care, and make them avallableelectronicalty to the providers treating you. The list of HiE Participant on the website will be updated regularly. • • You may also use this Consent Form to decide whether Dr not to allow employees, agents or members of the medical staff of The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai (together, 'Mount Sinai") to see and obtain access to your electionic health records through Healthlx, which Is a Health Irdormaton Exchange, or Regional Health Information . Organization eFtHICY), a not-fa-worn organIzaton reotygnfr.ad by the State of New York. This can also help tolled the medical records you have in different pleas Y.there you gat healthcare, and make them iVailable aledronlearly to the providers treating you. This oonsent gives your permission for any Mount Sinai program In which you are a patent to acars. your records from your other healthcare providers attn.-dried to cilarocee tritormatonihrough.Healthtt A complete list of - • — • current Healthix Information Sources is available from Health's and can be obtained at any lima by thecldng the Htialthix website at htto://www.healthixorq or by Sling Health's at 877-695-4749. Upon request your provider will printiNs fist for you from the Healthbr webalte• • YOUR CHOICE TO GIVE ORTO DENY CONSENT MAY NOT BE THE BASIS FORDENIAL OF HEALTH SERVICES OR HEALTH INSURANCE COVERAGE. • • .G.fr °4 IL.; ye toFEh THE iNFORMATIOR ON THE ATTACHED FACT SHEET, WHICH IS PART DE THIS CONSENT FORM, BEFORE MAKING YOUR DECISION. Your Consent choices You can fill out this form now or In the future. You hays the following chokes: Please cheek Boxl of 2: • m S I rVE CONSENT to ALL of than HIE Participant listed on the Mount Sinai HIE website to access ALL. —Grainy eleab-onroliealth- TrifditurdiailltrucgtrtheiMount-Sinal-HIEandIGIVL-GONSEMT-to-A1_4--amployeesr - agents and members of the medics] staff of Mount Sinai to access AU, of my electronic health Information through HEAD-lift in connection with cry of the permitted purposes described In the fact sheet Including providing me any hearth tare services, 'no:tiding emergency cam. 0 2. f DENY CONSENT ID ALL of tie HE-Participants listed on the Mount Sinai HIE website to access my electronic health information through the MountSinal HIE and I DENY CONSENT to ALL employee≤, agents and members of the medical staff of Mount Sinai to imeess.ANY. of my electordc health information through • HEALTKM for any purpose, &van In a atalcal emergency. NOTE: UNLESS YOU CHECKTHE'l MN CONSENT' BOX, New York State law allows hearth care - provitt-e.--s heating you In an emercency to gain aticas to your medical records, including records that are Svailabie through the Mount Sine. HIE and Healthiss. IF YOU DON'T MAKE A CHOICE, the records will only be shared to in emergency es allowed by applicable law. Pnnt Name of F-atent Patient Date of BIM Signature of Patient or Patent's Legal Represerbtrve . Dale - . . • Print Name of Legal Rapresentve (fi applicabe) Relatan.ShiP of Legal R spreser:&jvs rgent es applicably) EFTA00283631