4 Page U1/06 Vis 2072014 U4: loam on a #149 age SHINS. Mount Sinai Doctors “Fax Faculty Jo:__Les\ie Practice: Phon From: Dr. DiFebrizi Tena: Annette . Pulmonery, Critical Care and Sleep Medicine Prax: Pho Pages: Fax: Chrgest = OlPorReview OPleaseCommat PleassReply [) Pleas Recycle “= Please FAX Q copy of insuronce. card: + TH alony The document accompanying this transmission contains Information that may be confidential or privileged. This information is intended for the use Cf the individual or entity name above only and use by any other party is not authorized, The authorized recipient of this information is 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 contents of these documents is stritdy prohibited. !f you have received this information in error, please notify the sender immediately by phone. , EFTA00283626

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/U6 Uis 20/2014 U4: lbam = Mon | flag Fage 02/0) NS ENT om TEER i” pee Mount Faculty Practice Sinai OS NER me 2 Rete ee ath tee ee Oe De eye ie Doctors CONSENT FOR COMMUNICATION VIA E-MAIL (Provider-Patient) ZI, , hereby consent to have my physician, , communicate with me or members of his/her staff, where appropriate or other physicians, nurse practitioners ang pharmacists via e-mail regarcing the following aspects of my medical Care and treatment: [test results, prescriptions, appointments, billing, etc.]. I understand that e-mail is not a confidential method of communication. I further understand that there is a risk thet « mail communications between my physician and me or members of my physician's office staff or betweeh my physician and other Physicians, nurse practitioners and pharmacists xegarding my medical care and treatment may be intercepted by third parties or transmitted to’ unintended parties. I alse understand that any e-mail communications 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 wedical Care and treatment will be printed out.and made a part of my medical record. I understand that in an urgent or emergent situation I should call my Provider er go to the Emergency Room and not rely on e-mail. E-mail: _ Signature: EFTA00283627

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Ui/ 20/2014 U4: 16am = Non Fs #149 Page 03/06 The Mount Sing Medica) Center One Gustave L Levy Place New York, NY 10028-8574 The Mouat Sinzi Hospital Mount Sinai School of Medicine Mt. Siriai 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 bui zre not limited to the following: * Obtaining all necessary referrals from my Primary Care physician for visii(s) to specialists. » Obtaining ali 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 office of any change in my insurance coverage. Medicare Beneficiaries: » ) hereby authorize the release of medical and/or other information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers (including information relating to mental iliness and/or AIDS/ARC/HIV) necessary for this or any related Medicare claim. Ad] Patients: * [hereby authorize the release of medical and/or other information about me that is necessary for the processing of my insurance benefits. e. [hereby authorize payment on my behalf. ¢ Lhereby assign benefits payable to (provider) ] have read, understand and agree with the above. Name of Patient ; Daie Signature of Patient or Authorized Representative Date a Relationship to Patient Date aN ENP te ote Haye EFTA00283628

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#149 Page U4/Ub Of/ 29/2014 U4: lbam = Mon Fs Mount Faculty Practice Sinai Doctors ACKNOWLEDGEMENT OF RECEPT OF NOTICE OF PRIVACY PRACTICES’ . . ’. (NOPP) Patient Name : . Signature of Patient or Personal Represepiztive . ' Print Name of Patient or Personal Representative: . : . Date . , . , . . , . Description pf Personal Represontative Authority _ I was not able ‘to obtain the patient's acknowledgement of receipt of the NOPP Ubon regieration [1] The patient refisad to sign despite goad fath effarts : 7 ot ‘oO The patient was unacrompanied ani not alert and oriented . eee O., The patient was upaccomp lnfed and needed emergency care en DD Other, (emplaisys | 7 | ; Employee Signature Employes Title; . a MR-205 Rev 5/04)) * EFTA00283629

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Ul/2o/2Ul4 U4elbam = Won FY #149 Fage Uo/Ub MOUNT SINAI USE OF INFORMATION AUTHORIZATION Dear Patient, , Like other major academic medical centers, Mount Sinai depénds 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 néw requires health care providers to obtain your written _ authorization prior to contacting you with marketing information or about philanthrogj¢ initiatives that support the work of your doctors. Your permission for disclosure of your name will allow Mount Sinai staff 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. Maintaining 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 moment to read this authorization and sign below. If * |o= 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 Mount 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 witl not be affected in any way by my refusal or failure to sign this form. I further understand that this authorized information will not be released to any third 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 Deveiopment Office, One Gustave L. Levy Place, Box 1049, New York, New York 10029-6574. By signing below, I acknowledge that Ihave read and accept all of the above, Signatwre.of Patient Print Name of Patient or Personal Representative /' Guardian or Personal Representative/ Guardian x . Address of Patient If Applicable, Description of Authority of Personal Representative/ Guardian A signed copy of this form is available upon request by patient or patient representative OFFICE USE ONLY. MR-212 (REV 4/08) EFTA00283630

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Viseo/2014 U4: T fam = Mon | kel #149 Page U6/Ub ? —s eh ene ere EE en anew Se rh Reet EL, eset he ig ‘MOUNT. SINAI HEALTH INFORMATION EXCHANGE ~" AND KEALTHIX CONSENT FORM a el hp ema ee, The Mount Sinai Health informatios Exchange (‘Mount Sinal HIE") and Healthlx share information about people's health electronically end securely tc Improve the quality of heelth care services. This kind of sharing 's called ehealth or health information jechnslagy (“Health 'T). Ts lear mare aboul Health !T in New York State, read the brochure, “Better information Means Better Carc.* You can ask your health care provider for il, or go tp the website www.ehealthény.orq. , In this Consent Form, you can choose whether to aliow the health-care providers listed on the Mount Sinai HIE website yaw mountsinaicontectorg (HIE Participants’) to cbtain 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 avaliable electronically to the providers treating you. The list of HIE Participants on the website will be updated regularly, © . a ‘You may also Use this Consent Form tp decide whether or not to allow amployees, agents or members of the medica! siaft of ‘The Mount Sina] Hospital and Icahn School of Medicine st Mount Sinai (topether, “Mount Sinai") to see and obtain access {5 your electtonic health records through Hesitht, which Is a Hesith Information Exchange, or Regional Health Information *. Oranization {"RH!O}, 2 not-for-profit organization recognized by the State of New York. This can also halp collect the medical records you have In diferent plecas where you oat healthcare, and meke thet 2Vvailabls electronically te the providers treating you, This conser gives your permitsion for any Mount Sinai program In which you are 8 patient io access. your records from your other healtheare providers suthorizsd to disclose Information through Healthix. A complete list of * ‘~~: “current Healthix Injormaiion Sources is avaliable from Healthix and can be obtained at any tima by checking ths Health website at http/Awww.beaithixorg or by calling Health at 877-695-4748. Upon request, your provider will print.this Iist for you from the Healthix website. ; é YOUR CHOICE TO GIVE ORTO DENY CONSENT MAY NOT SE THE BASIS FOR DENIAL OF HEALTH SERVICES OR HEALTH INSURANCE COVERAGE - : _ | ——BLEASE CARE ON ON THE ATTACHED FACT SHEET, WHICH IS PART OF THIS - CONSENT FORM, BEFORE MAKING YOUR DECISION. TO Your Consent Cholces. Youcan fill out this form now or In the future. You have tha following choles: Please check Box 4 of 2: . : . f O ALL of tha HIE Part!cipants listed on the Mount Sinai HIE websits to access Ali: ” Sf ny electronit health information throug tis Mount Sinel Hie an 5 to ALL employees — agents and members ofthe madical staff of Mount Sinal to access ALL of my electonic health information through HEALTHEX in connecien with any of the penmitted purposes desorbed In the fact sheet, Including providing me any health care services, including emergency care, ‘ 0 2. | DENY CONSENT to ALL of this HE Participants listed on the Mount Sinai HIE website to access my electronic health information through the Mount Sinai HIE and | DENY CONSENT to ALL employees, agents and members of the medical staff of Mount Sinal to access, ANY, of my electonic health Information through -.. . HEALTHIX for any purpose, aven in a medica! emergency. . NOTE: UNLESS YOU CHECK THE™| DENY CONSENT" BOX, New York Stats lew allows health care ’ providers tresiing you In an emergency to gain accass to your medical records, including records that aya evailabia through the Mount Sinai HIE and Healthix. [F YOU DON'T MAKE A CHOICE, tha records will only be shared [n an emergency es allowed by applicable lew. . " 'Brint Name of Palent ~ PaientDaeofBimh SSS . Signature of Patient or Patient's Legal Represetative : Date ; . re oo - Print Name of Legs! Rapresentativa (i epplicadis) Relagonship of Legal Respresentsiys te Pafark (f eppficabls) EFTA00283631