EFTA00311062.pdf

Columbia Orthopaedic Surgery PATIENT DEMOGRAPHIC INFORMATION DR. MRN: LAST NAME EPS i el 13 FIRST MI e AGE SI SEX S/ F ADDRESS Ci earl- 1 sr sr) t.IN,r-i`i /0 0a-1 APT.# ZIP CODES CITY/STATE HOME PHONE CELL PHONE EMAIL ADDRESS jecvo_cAcci-i mot, I. 0 001 MAIDEN NAME MOTHERS FIRST NAME PA A, L.- A EMPLOYER (Fitiapietm. -rtzu ST CDR P) BUSINESS PHONE FATHER'S FIRST NAME SE4 LAP-- DATE OF BIRTH (or) geb 1-I DID QuAtta2$, v3-3 POfOp- EMPLOYER'S ADDRESS EMERGENCY CONTACT NAME RELATIONSHIP TO PATIENT FtLia.lb ADDRESS HOME PHONE WORK PHONE INSURANCE INFORMATION PRIMARY INSURANCE NAME 1.4-4 i Tell 14 ADDRESS OF INS. COMP. -P C -4 -4 -01( DO I A-a-AntlA eA gn31-4 -Oft 0 TEL* OF INS. COMP. - CONTACT PERSON IC* GROUPIPOLICY# NAME OF POLICY HOLDER 1 -16 1:- r 2 EY CPS-r-Ei"-i PATIENTS RELATIONSHIP TO POLICY HOLDER Ret..-F EMPLOYER OF POLICY HOLDER ri NA TIZU tr CO• fri-c) EMPLOYER'S ADDRESS/PHONE tele° iaet HOOK GL1AR-i'etS P-3, S-7-1-10 L4 LAS1 crib. SECONDARY INSURANCE NAME ADDRESS OF INS. COMP. TEL.* OF INS. COMP. CONTACT PERSON ID* GROUP/POUCWI NAME OF POLICY HOLDER PATIENTS RELATIONSHIP TO POLICY HO r R EMPLOYER OF POLICY HOLDER EMPLOYERS ADDRESS/PHONE NO FAULT CASE INFORMATION ACCIDENT DATE/TIME CLAIWFIL PHONE INSURANCE NAME CO ACT PERSON ADDRESS WORKER'S COMPEN ATION INFORMATION ACCIDENT DATE/TIME CLAIM/FILE# PHONE INSURANCE NAME CONTACT PERSON ADDRESS Scan Folder: Registration Form Revised 06/29/2011 EFTA00311062 Orthopaedic Clinical Intake Form MRN: Age: 5-9 Date of Birth: Today's Date: I 3 O Preferred Lan ua C IS El Referring Ph sician: Phone: Address: Primary Care Doctor: Address: Phone: Pharmacy Name: OL.Niccets vt4Ag Pt eC`i Phone: Address: got M Mice/4 AVE rGOi 4Je-r— .3.41b4 PAD SO"./ What is the reason for your visit today? Location of pain (include side): How long has it been present? Describe pain: dull sharp tingling other When does pain occur? at rest with activity at night other Any other symptoms associated with current problem? Severity: on a scale from 1-10, indicate how severe the pain is on the scale below with I being very little pain to 10 being excruciating/can't function (circle number): 1 2 3 4 5 6 7 8 9 10 Indicate what makes it better? pain medicine ice heat rest elevation Context: How did it occur? Are you right or left hand dominant? If result of injury, date occurred Is it better? Is it worse? PAST MEDICAL HISTORY: Please list past medical conditions below Asthma No Yes DVT/PE (Blood Clot) No Yes Blood or plasma transfusions No Yes Heart Disease No Yes Cancer No Yes Lung disorder No Yes Cholesterol No Yes Stomach/Intestinal disorder No Yes Clotting disorder No Yes Thyroid problems No Yes Diabetes No Yes Hypertension No Yes *Other: PAST SURGICAL Please list any surgeries you have had: Type of Surgery Approx. Date Complications if any Have you ever had general anesthesia? Have you had any problems with anesthesia? Describe: Scan Folder: Onho Intake Form Page 1 of 4 Revised 2/2/12 EFTA00311063 Name: Orthopaedic Clinical Intake Form MRN: Zre CRS- ERT1 e Date of Birth: MEDICATIONS. VITAMINS. SUPPLEMENTS & HERBS: Please list all medications, vitamins, supplements and herbs you are currently taking including dosage in the lines below: Name Dosage/Amount ALLERGIES: Please list allergies and reaction or write "NONE"(include medications, environmental agents, food, other) Allergy Reaction Allergy Reaction SOCIAL HISTORY: Occupation: -BA Marital Status: 6 Home: 1 story 2 story -i- entrance steps `I apartment elevator Do you a exercise tob u regularly? er? id Cigarettes? In volved tg in school sports? you Are Smokeless Tobacco? Other? Average per day? # of years? If no, have you ever? Do you currently consume alcohol? Average # per wk? If no, have you previously? Do you currently use drugs? NI o FAMILY HISTORY: Please indicate any major conditions/illnesses for family members below. Relative Alive (aae) Deceased (aae) Cause of Death Mother Father Siblings Other Health Problems Scan Folder: Onho Intake Form Page 2 of 4 Revised 2/L/2 EFTA00311064 Orthopaedic Clinical Intake Form MRN: Name: Tre Pc R e7s-rErNi REVIEW OF SYSTEMS: Are you currently having or have you had problems with your: alyes, check box to right of symptoms that apply) Constitutional Elm Ears,Nose,Throat Lungs, Breathing Heart Gastrointestinal Bladder Endocrine Musculoskeletal Bleeding Neurological Integumentary Psychiatric Immunologic/ Anemic Date of Birth: No/ Yes Fatigue° Headache° Fever° Weight Loss° Other: No / Yes Glasses° Blurred vision0 Other. No / Yes Congestion° Hearing Loss° Jaw discomfort° Other: No / Yes Cough° Wheezing° Shortness of breath° Other: No / Yes Heart munnursO Irregular heartbeat° Other: No/ Yes Nausea0 Vomiting° Stomach aches° Constipation° Diarrhea° Other: No / Yes Incontinence° Urinary tract infections° Difficulty urinating° Other: No / Yes Diabetes° Thyroid problems° Delays in growth° Other. No / Yes Joint pain0 Leg painO History of broken bones° Other: No / Yes Anemia° Prolonged Bleeding after cut/injwyD Other: No/ Yes Dizziness° Numbnesshingling0 Headaches° Frequent fallsO Other: No / Yes Rashest] Skin Disorders° Connective tissue disorders° Other. No / Yes Change in mood or behavior° Change in sleep patterns° Other: No / Yes Asthma° Hay fever° Chronic rashest] Communicable Diseases° Other: Signature (Person Completing Form) Physician Signature Date Completed Date FOR OFFICE USE ONLY: Initials below indicate Allergies, Medications, and Problems have been data entered as discrete elements into the CROWN System. Additionally, the indicated elements of Section #1 have been data entered into the CROWN System as discrete data: Family History Past Medical History Past Surgical History Social History Initials Scan Folder: Onho Intake Form Page 3 of 4 Revised 2/2/12 EFTA00311065 Orthopaedic Clinical Intake Form MRN: Name: Jec-- cr-g 6"! 09S -ra I A-1 Date of Birth: WORKER'S COMPENSATIO\ & No FAULT If this problem is related to a work or car Accident, please complete the following questions: Work related? Car accident related? Date of accident/onset Which part(s) of your body was injured (include side)? Prior to this accident, did you have a problem/pain in the affected area? Did you sustain other injuries due to this accident? If yes, please give details (ex: left hand laceration): Did you have immediate pain of the affected area at the time of the accident or a few days later? Where (address with state) and how did the injury occur? Job title on date of injury What were your usual work activities on the date of the injury/onset? Employer when injury occurred (include address and phone #): Have you been treated by another health care provider for this injury? If so, give details Are you currently working? If Yes, regular or modified duties (if modified, give details)? If you are Not working, what is the date you first missed work due to this injury? Are you being counseled by a lawyer for this injury? If car accident, where you the driver or passenger? Did the air bag deploy? Where you wearing your seat belt at the time of the accident? Signature (Person Completing Form) Date Completed Scan Folder: Ortho Intake Form Page 4 of 4 Revised 20/12 EFTA00311066 New York Orthopaedic Hospital Associates Date: P1/4"Pg1 I- Ca Christopher S. Ahmed, M.D. Louis U. Bigliani, M.D. Edwin R. Cadet, MD. Jeffrey A. Geller, M.D. Justin IC Greisberg, M.D. Joshua E. Hyman, M.D. Yongiung Kim, M.D. Francis Y. Lee, M.D. Jonathan Lee, MD. William N. Levine, M.D. William B. Macaulay, M.D. Christopher B. Michelsen, M.D. Ohanncs A. Ncrcessian, M.D. Melvin P. Rosenwasser, M.D. Benjamin D. Roye, M.D. David P. Roy; M.D. Robert J. Strauch, M.D. Peter Tang, M.D. J. Turner Vosseller, M.D. Michael G. Vitale,M.D. Mark Weidenbaum, M.D. Nicole Baiton, NP. Carmela Evangelism, NP Rachael Lyons, DPN Patient Name: Ter F9.-E-4 EPSTIE) DOB: MAN: Thank you for choosing the New York Orthopaedic Hospital Associates (NYOHA). We are committed to the success of your medical treatment and care. We understand that many patients find insurance coverage and financial responsibility issues complex and confusing. Because of this, we have outlined our practice's policy in detail. If you have any questions about our policies, our staff is happy to assist you. What Is My Financial Responsibility? Your financial responsibility depends on a variety of factors, explained below. Please check off which insurance type applies to the patient. Patient Payment Policy Payment for Office Visits and Services I I 1 on I l.n c... O Commercial insurance Also known as indemnity, or "regular" insurance. You Are Responsible For... Paying for services at the time of the visit. N. \ ( H I \ '1/4\ ill .. Provide you a receipt so you can file the claim with your carrier. O Managed care plans with which NYOHA has a contract Obtaining referral authorization from your primary care physician if needed Paying your deductible, copay, and any services that arc not covered by your plan, at the time of your visit. Inform you of any services not covered by your plan. File the insurance claim. O Out of netnork PPO or FINIO plans Paying your deductible and full charges at the time of the visit. File the insurance claim. O Regular Nletlieare Paying your deductible if it is not yet met, as well as any services not covered by Medicare. If you do not have secondary coverage or Medigap, you will also be asked to pay the 20% Medicare coinsurance. File the Medicare claim, as well as any claims to your secondary insurance. O \led:eaid Obtaining a referral authorization from your primary care physician as needed. No payment is due at the time of service. File the Medicaid claim. O Worker's Compensation If you supply our staff with a valid case number Call your carrier ahead of time to verify the accident date, claim number, primary care physician, employer information, and referral procedures. adiustcr name and ohonc number. no payment is necessary at the time of the visit. O Uninsured or Major Medical only Paying for services at the time of the visit. Work with you to settle your account. O Third Party Liability and Accident victims Paying for services at the time of the visit. File the claim, according to the rules stated by your primary insurance carrier. O Personal Injury Payment for services at the time of the visit. Cooperate with your attorney to provide copies of records and reports. (At an additional charge.) Scan Folder: Payment Policy 1 Revised 07/1/2011 EFTA00311067 do ColumbiaDoctors The Physicians and Surgeon, of Columbia University Christopher S. Myriad, M.D. Louis U. Bigliani, M.D. Edwin R. Cadet, MD. Jeffrey A. Geller, M.D. Justin K. Greisbetg, M.D. Joshua E. Hyman, M.D. YongJung Kim, M.D. Francis Y. Lee, M.D. Jonathan Lee, MD. William N. Levine, M.D. William B. Macaulay, M.D. Christopher B. Michelsen, M.U. °henries A. Nercessian, M.D. Melvin P. Rosenwasser, M.D. Benjamin D. Roye, M.D. David P. Roye, M.D. Robert J. Strauch, M.D. Peter Tang, M.D. J. Turner Vosseller, M.D. Michael G. Vitale, M.D. Mark Wcidenbaum, M.D. Nicole Baiton, NP. Camiela Evangelista, NP Rachacl Lyones, DPN PATIENT ACKNOWLEDGMENT OF THE NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided with a copy of the Columbia University Health Sciences Notice of Privacy Practices. P‘FRIL- 1. 1D-O1D- Patient Name Date Signature of patient or personal representative If personal representative, Personal representative's authority to act Scan Folder: Hipaa Revised 06129/2011 EFTA00311068 dos ColumbiaDoctors the Physicians and Surgeons of C,ohanbia University The Federal Government requires us to ask these questions. This information is used to track illnesses by age, gender, race and ethnicity. We will also use this information to identify the needs of different patient groups and develop plans to address them and monitor the quality of our services for all patients so everyone gets the highest quality care regardless of their racial or ethnic background. We ask that you check one box under each category and thank you for taking the time to complete this information. Name: 7) Date of Birth: MRN#: Ethnicity: O Decline Response (I do not wish to answer) In Hispanic or Latino O Not Hispanic or Latino Race: In Decline Response ( I do not wish to answer) American- Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or other Pacific Islander White Other KKKKKKK Preferred Language: 0000000 000000000 Decline Response ( I do ARABIC CHINESE CZECH DUTCH ENGLISH FRENCH GERMAN GREEK HEBREW HINDI INDONESIAN ITALIAN JAPANESE KOREAN MALAY not wish to answer) K Other CI PERSIAN CI POLISH K PORTUGUESE CI ROMANIAN O RUSSIAN O SIGN LANGUAGE O SLOVAK O SPANISH In SWAHILI In TAGALOG In THAI CI TURKISH CI URDU O VIETNAMESE Visit Date: AR;2 IL- IS, 0 YIDDISH DO NOT SCAN THIS DOCUMENT EFTA00311069 MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) , ("Assignor") hereby assign to (Print patient's name) , ("Assignee") all rights privileges and remedies to payment (Print provider's name) for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law. The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on , not withstanding any other (Date of accident) agreement to the contrary. This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. (Print name of Patient) (Signature of Patient) (Date of Signature) (Address of Patient) (Print name of Provider) (Provider Address) Scan folder: Payment Policy P: APP NF A0B_20122301 EFTA00311070 tm oarn ...i cn ,a cn .c_ av - 1 2 0 MI 0 0 -1 0 - 0 0 -101r. x.,, 0 73 m w I IA IA t% owl 2 rn rn Q. K 05 > 0 I--. -.4 ra 2 8 (1th w>:r . , cr .,-. .r• < IO - 0-1 < 0 4., g. •-. x co o gjn a E li o c o co To to g$1i Co X) -. cr -i N rn o 8IF . m o co o co o w 0 0 I Oa 0 (A IN UnitedHealthcare* Health Plan (80840) • Member member: JEFFREY EPSTEIN I Ohre: S20 Wart S75 Spec 330 ER: $200 c) h. O ... llnitedHealthcare Choice Plus oo • OW' InOtnetio, Of l.k.ionsulegaro mammal Canoe? Group Number: FINANCIAL TRUST COMPANY Payer ID pmser nis cardomii rjoesthenotwemite gocaste s or ca- 9B. To verify betas. For Members: www.myuhc.com Care24: Mental Health: For Providers: www.undedhealthcareonlIne. Medical Claims: P.O. BOX 7408® ATLANTA GA3037 Portal 18121109 clams, or Fonda cemeccocce YAW liMuiriPter Pharmacy Claims:PO BOX 14711, LEXINGTON KY 40512 Foe Pharmacists 800122-155T EFTA00311071 Li/ Zell ME PSC gain CARDIUVASt 114AG PAGE 81 Ed1500 Imaging AS80. 9/23/2011 9:15:30 AM PAGE 1/001 Fax Server Advanced Cardiovascular ffl aging ,r-,_:35! 38in St New York. hrte 1012S Phone Steven D. Wolff, M.D., Ph o Director Rony Semen/ 110 E 59 St Ste 8A New York. WY 10022 Patient ame: EPSTEIN, JEFFREY DOB: 01 1953 Exam Mod: 09/22/20115:55 PM ACC: MRN: PAM= Examination LUMBAR SPINE MR1 Comparison None meltable Clinical History Pain in back and legs Technique Sagittal FSE. Axial FSE. Sepal FLAIR T1. Sagittal IR Findings There is minimal degenersthe grade 1 anterollethesis of L4 on L5. Conus ends normally at the IOW T12 level and appears ireirsically normal. Thee is no acute fracture. T11.112.L2-L3 there s no bee disc herniation or stenosls. 13-L4. there is disc bulge and facet arthrosie. 144.5. there is anterolistheeis. there is broad disc bulge with facet arthrosis enc ilgamentum Swim hypertrophy. There is severe central Canal. subansular and moderate to marked trammel stenosts. There is impingement of the L5 and encroachment on the exiting L4 nenes. 15-S1 them is disc bulge asymmetric to Me right with right greater than let est t Orin:eels. There Is mild to moderate right subarticular ster1Cals with encroachment on the right S7 none. Impression Seem 14.15 and to a lesser degree right-sided 1.5-S1 stenoSiS. Thank you tor the cotateey of this referral. Dictated by: Jilani. Mohammad MD Electronically Signed By: JUN. Mohammad. MO 09/23ran 9:14 AM lranscrihnd by: Mohammad. MD on September 23, 2011 9:14 AM EFTA00311072 ColumbiaDoctors The Physicians and Surgeons of Columbia University April 03, 2012 Jeffrey Epstein 301 East 66th Street Suite 10b Palm Beach, FL 10065 Re: EPSTEIN,JEFFREY MRN: IDX00938430 Department of Orthopaedic Surgery Appointme • Department Tel. We are proud to welcome you as a new patient of Mark Weidenbaum, MD. You can feel confident in knowing you are now in the care of one of the top doctors in the nation. His reputation has helped our medical center remain ranked as a leader in orthopedics. Your appointment is scheduled for: 04/13/2012 11:45AM For your consultation with Mark Weidenbaum, MD. Please arrive one hour earlier if you are scheduled for an x-ray. 161 Ft. Washington Avenue 2nd Fl New York, NY (Directions are enclosed) To ensure your first visit with us meets your expectations, we have provided a checklist of items to help you prepare. We have also enclosed documents for you to complete at your convenience and bring with you. Check list: K Patient Demographic Information: Please complete and sign. Please make sure you have included your referring physician and/or primary care physician(s) contact information, so we can coordinate your care. If you need assistance with completing any part of the enclosed forms, our staff will be happy to help you on the day of your appointment O Medical History • Medical History Form. Please complete and sign. • Copies of relevant medical records including all surgical reports and test results. • Radiological films and reports such as x-rays, MR1 or CT scan, etc. • Medications you are currently taking. (Please bring actual bottles or containers) O Payment Information: Payment is due at the time of your visit. • Patient Payment Policy is enclosed for you to review and sign. • Please bring your Insurance card(s). • Insurance referral if applicable. If you are on a managed care plan with which our doctor participates, please ensure that you obtain necessary referrals. Patients are responsible for payment in full if referrals are not received by the time of the visit. • Payment can be made using cash, check or credit card. • Charges for ancillary testing such as laboratory, radiology and other tests may be billed to you separately. K Notice of Privacy: •Note if you have previously signed a notice of Privacy for any Columbia NYPH Provider you will not have to sign a new one. • Please sign and return the Patient Acknowledgment of the Notice of Privacy Practices. We look forward to your visit and providing you with the care you deserve. We understand busy schedules, so if you need to cancel or reschedule your appointment please let us know 24 hours prior to your appointment. This will allow us to reschedule at your convenience, and provide a patient on our waiting list with the same opportunity. Please call our office at (212) 305- 4565. Sincerely, Pre-Appointment Scheduling Department Columbia Orthopaedics Columbia University Medical Center EFTA00311073 Herbert "Irving" Pavilion 161 Fort Washington Avenue, 2" Fl New York, NY 10032 Between Riverside Drive and Broadway Corner of 165th St. and Fort Washington Ave. From George Washington Bridge:1 Exit onto Henry Hudson Parkway, and then onto the Riverside Drive South. Continue on Riverside Drive until 165th Street. Make left onto 165th Street. Go up 1 block to Fort Washington Avenue. Make left to Herbert Irving Pavilion or make right to parking garage and then walk to Herbert Irving Pavilion. From Saw Mill River Parkway: Exit the Henry Hudson Parkway at the Riverside Drive exit. See directions from Riverside Drive above. From Westchester, Connecticut, and the East Side of Manhattan via major Deegan, Cross Bronx Expressway or Harlem River Drive: Approaching the George Washington Bridge, take the Henry Hudson Parkway exit, stay on the left and follow signs to Broadway. Make left onto Broadway. Continue on Broadway until West 165th Street. Make right onto West 165th Street. Continue one block to Fort Washington Avenue. Make right onto Fort Washington Avenue to Herbert Irving Pavilion or make left to parking garage and then walk to Herbert Irving Pavilion. From West Side of Manhattan: Take Henry Hudson Parkway to exit 15-Riverside Drive South. Follow directions from Riverside Drive South above. Public Transportation: Via subway- A, C, 1 or 9 train to 168th Street and Broadway. Bus - M2, M3, M4, M5, M100, or BX7 Parking: Parking is available at the corner of 165th Street and Fort Washington. Valet Parking is available at the Milstein Hospital Building next door. Radiology: If you are scheduled for an x-ray, you should report to our 2nd floor reception desk to pick up the requisitiop before proceeding to the Radiology Department on the 1.1 floor. lip" IP'S‘c. • I +,•e+ s,„, • %, OTAS ',AVM> W so• St W 4fU. ...FOY low.. 0 0o o C rd , S fr ni.n.,,IgA or waren-i nwts "0000a cr.'s.. a a aft EFTA00311074 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice This Notice will tell you about the ways we may use and disclose health information that identifies you ("Health Information"). We also describe your rights and certain obli- gations we have regarding the use and disclosure of Health Information. We are required by law to maintain the pri- vacy of Health Information that identifies you; give you this Notice of our legal duties and privacy practices with iespeu to your Health Information; and follow the terms of our Notice that are currently in effect This Notice covers the faculty physician practices of Columbia University Medical Center ("Columbia University", "Columbia", "we" or "us"), including its employed faculty physicians and faculty physicians practic- ing on Columbia University owned or leased space, as well as their clinical support staff This Notice also covers Columbia University Health Care, Inc.; the Ophthalmology Faculty Practice Corporation; Orthopedics, P.C.; Neurosurgery, P.C.; and Urology P.C. (all "Columbia University"). If Columbia physicians or health care professionals provide you with treat- ment or services at another location, for example New York Presbyterian Hospital, the Notice of Privacy Practices you receive at such other location will apply. COLUMBIA UNIVERSITY MEDICAL CENTER How we may use and disclose health information about you The following categories describe different ways that we may use and disclose Health Information. For Treatment We may use Health Information about you to provide you with medical treatment or services. We may disclose Health Information to doctors, nurses, technicians, medical stu- dents, or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes, because diabetes may slow the healing process. Different departments of Columbia University also may share Health Information such as prescriptions, lab work and x-rays to coordinate your treatment. We also may disclose Health Information to people outside Columbia University who may be involved in your medical care. For Payment We may use and disclose Health Information so that we may bill for treatment and services you receive at Columbia University and can collect payment from you, an insurance company or another third party. For example, we may need EFTA00311075 to give your health plan information about your treatment in order for your health plan to pay fix such treatment. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. In the event a bill is overdue we may need to give Health Information to a collection agency as necessary to help collect the bill or may disclose an outstanding debt to credit reporting agencies. For Health Care Operations We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive qual- ity care and for our operation and management purposes. For example, we may use Health Information to review the treatment and services you receive to check on the performance of our staff in caring for you. We also may disclose information to doctors, nurses, technicians, medi- cal students, and other personnel for educational and learn- ing purposes. The entities and individuals covered by this Notice also may share information with each other for pur- poses of our joint health care operations. Appointment Reminders/Treatment Alternatives/ Health-Related Benefits and Services We may use and disclose Health Information to contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you. Fundraising Activities We may use your demographic information to contact you in an effort to raise money for Columbia. Any fundraising letter you receive from us will provide you with instructions on how to opt out of any future fundraising letters. We will not use your diagnosis to fundraise unless you authorize us to do so in writing. Individuals Involved in Your Care or Payment for Your Care We may release Health Information to a person who is involved in your medical care or helps pay for your care, such as a family member or friend. We also may notify your fam- ily about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. Research Under certain circumstances, we may use and disclose Health Information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose Health Information for research, however, the project will go through a special approval process. This process evaluates a proposed research project and its use of Health Information to balance the benefits of research with the need for privacy of Health Information. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for similar purposes, so long as they do not remove or take a copy of any Health Information. As Required by Law We will disclose medical information about you when required to do so by international, federal, state or local law. To Avert a Serious Threat to Health or Safety We may use and disclose Health Information when neces- sary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will be to someone who may be able to help prevent the threat Business Associates We may disclose Health Information to our business marl- ates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to EFTA00311076 perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or dis- close any information other than as specified in our contract Organ and Tissue Donation If you are an organ or tissue donor, we may release Health Information to organizations that handle organ procure- ment or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation. Military and Veterans If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. Workers' Compensation We may release Health Information for workers compensa- tion or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks We may disclose Health Information for public health activities. These activities generally indude disclosures to: a person subject to the jurisdiction of the Food and Drug Administration ("FDA") for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; prevent or control dience, injury or disability; report births and deaths: report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using a person who may have been exposed to a disease or may be at risk for contracting or spread- ing a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and the patient agrees or we are required or authorized by law to make such disclosure. Health Oversight Activities We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspec- tions, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement We may release Health Information if asked by a law enforce- ment official for the following reasons: in response to a court order, subpoena, warrant, summons or similar process; lim- ited information to identify or locate a suspect, fugitive, mate- rial witness, or missing person; about the victim of a crime g under certain limited circumstances, we are unable to obtain the person's agreement; about a death we believe maybe the result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, descrip- tion or location of the person who committed the crime. National Security and Intelligence Activities and Protective Services We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We also may disclose Health Information to authorized federal officials so they may conduct special investigations and provide protection to the President, other authorized persons and foreign heads of state. Coroners, Medical Examiners and Funeral Directors We may release Health Information to a coroner, medical examiner or funeral director so that they can carry out their duties. Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforce- ment official. This release would be if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution. How to Learn About Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact the Privacy Officer for more information about the protections. Other Uses of Health Information Other uses and disclosures of Health Information not cov- ered by this Notice or the laws that apply to us will be made only with your written permission. You may revoke your permission at any time by submitting a written request to our Privacy Officer, except to the extent that we acted in reliance on your permission. EFTA00311077 Your Rights Regarding Health Information About You You have the following rights, subject to certain limitations, regarding Health Information we maintain about you: Right to Inspect and Copy You have the right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request_ Right to Request Amendments If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information and you must tell us the reason for your request. You have the right to request an amendment for as long as the informa- tion is kept by or for Columbia. A request for amendments must be submitted, in writing, to the Privacy Officer at the address provided at the end of this notice. Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures" of Health Information. This is a list of certain disclosures we made of Health Information. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. Right to Request Restrictions You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we agree, we will comply with your request unless we terminate our agreement or the information is needed to provide you with emergency treatment. Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You may obtain a copy of this Notice at our web site, http://vnvw.cumc.columbia.edufhipaat How to Exercise Your Rights To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the end of this Notice. Alternatively, to exercise your right to inspect and copy Health Information, you may con- tact your physician's office directly. To obtain a paper copy of our Notice, contact our Privacy Officer by phone or mail. Changes To This Notice We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for Health Information we already have as well as any informa- tion we receive in the future. We will post a copy of the cur- rent Notice at each Columbia physician office or outpatient location and on our website. The end of our Notice will con- tain the Notice's effective date. Complaints If you believe your privacy rights have been violated, you may file a complaint with Columbia or with the Secretary of the Department of Health and Human Services. To file a complaint with Columbia, contact our Privacy Officer at the address listed at the end of this notice. You will not be penalized for filing a complaint. COLUMBIA UNIVERSITY MEDICAL CENTER Questions If you have a question about this Privacy Notice, please contact: Privacy Officer Office for HIPAA Compliance Columbia University Medical Center 601 West 168th Street Apartment 22 Effective date: April 14, 2003 New York, NY 10032 Revised date: October 22, 2007 Phone E-mail: Website: www.cumc.columbia.edu/hipaa EFTA00311078