Columbia Orthopaedic Surgery PATIENT DEMOGRAPHIC INFORMATION DR. MRN: vast NaME__E TST Ei AN FIRST__\ rE eeeey mE ace 57 sex(qir aporess__ G EAST BIST ST NY NY sOOS| APT# CITY/STATE ZIP CODE >} HOME PHONE _~ CELL PHONE. EMAIL ADDRESS \EEN acet on BAA NG {. COM MAIDEN NAME MOTHER'S FIRST NAME ae : pare oF e1nT [i EMPLOYER c ST core EMPLOYER'S ADDRESS. J EMERGENCY CONTACT FATHER'S FIRST NAME SEY A4 DUR. BUSINESS PHONE | 3 - TaS HOME PHONE work Hone J INSURANCE INFORMATION PRIMARY INSURANCE NAME__LLN ITED HEALTH CARE } ADDRESS OF INS. COMP,_"} 2 are 7 3 . 0 TEL# OF INS. COMP. . - ¥45 - CONTACT PERSON, ID# GROUP/POLICY#. fT NAME OF POLICY HOLDER_ .)EFFREY EPSTEIAI PATIENT'S RELATIONSHIP TO POLICY HOLDER_S EL = EMPLOYER OF POLICY HOLDER__F / TRUST ). Te EMPLOYER'S ADDRESS/PHONE__ (2100 BED HOOK QUARTERS A-3) ST THOMAS LaSVt oofos SECONDARY INSURANCE NAME ADDRESS OF INS. COMP. 4 TEL# OF INS. COMP. KO CONTACT PERSON ID# GROUP/POLICY# NAME OF POLICY HOLDER Xx PATIENT'S RELATIONSHIP TO POLICY HOLDER EMPLOYER OF POLICY HOLDER / EMPLOYER'S ADDRESS/PHONE_ f NO FAULT CASE INFORMATION / ACCIDENT DATE/TIME CLA@ PHONE INSURANCE NAME ( CONTACT PERSON ADDRESS WORKER'S COMPENSATION INFORMATION ACCIDENT DATE/TIME CLAIM/FILE# PHONE INSURANCE NAME CONTACT PERSON ADDRESS Scan Folder: Registration Form Revised 06/29/2011 EFTA00311062

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Orthopaedic Clinical Intake Form MRN: _ _ Today’s Date:_ APRIL (3. 30\3>. Name: || EF FREY EPS TEI! Age: 5 9 Daie of Birt Gender: MALE Height Weight: Preferred Language: ENGLISH Referring Physician: : Address: Primary Care Doctor: SAME Phone: Address: PharmacyName: _G@LYDE'S PUARMECY Phone: Address:_ Fo MADISON AVE (CopgnNne?t Q44™ = praDpisoal What is the reason for your visit today? Location of pain (include side): Are you right or left hand dominant? How long has it been present? Describe pain: dull sharp tingling other When does pain occur? atrest 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 | being very little pain to 10 being excruciating/can’t function (circle number): 123 45 67 8 9 10 Indicate what makes it better? pain medicine ice heat rest elevation Context: How did it occur? 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 History: 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: Ortho Intake Form Page | of 4 Revised 2/2/12 EFTA00311063

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Orthopaedic Clinical Intake Form MRN: 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: “BANWE? Marital Status: ‘9 Home: | story___ 2. story_+_ entrance steps_Y apartment__ elevator Y__ Do you exercise regularly? __—s Involved in school sports? Are you a tobacco user? Ne Cigarettes?___—s Cigars?__—s Smokeless Tobacco? _ Other? Average perday? ss # of years?___—sIfno, have youever? Do you currently consume alcohol? Nc Average # per wk? __If no, have you previously? __ Do you currently use drugs? N ° FAMILY History: Please indicate any major conditions/illnesses for family members below. Relative Alive (age) Deceased (age) Cause of Death Health Problems Mother Father Siblings Other Scan Folder: Ortho Intake Form Page 2 of 4 Revised 2/2/12 EFTA00311064

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Orthopaedic Clinical Intake Form MRN: Name: JEFFREY EPSTE inl Date of sir: i REVIEW OF SYSTEMS: Are you currently having or have you had problems with your: (If yes, check box to right of symptoms that apply) Constitutional No/Yes Fatigue) Headache) FeverO Weight LossO Other: Eyes No/Yes GlassesO Blurred vision Other: Ears,Nose,Throat No/Yes Congestion Hearing LossO Jaw discomfortO) Other: Lungs, Breathing No/Yes CoughO) WheezingO Shortness of breathO Other: Heart No/ Yes Heart murmursC) Irregular heartbeatO) Other: Gastrointestinal © No/Yes Nausea) VomitingO Stomach achesO ConstipationO) DiarrheaD Other: Bladder No/ Yes IncontinenceO) Urinary tract infections Difficulty urinating Other: Endocrine No/ Yes DiabetesO) Thyroid problemsO) Delays in growthO Other: Musculoskeletal No/Yes Joint painO Leg painD History of broken bonesO Other: Bleeding No/Yes AnemiaQ Prolonged Bleeding after cut/injuryO Other: Neurological No/ Yes DizzinessO Numbness/tingling0 HeadachesO) Frequent fallsO Other: Integumentary No/ Yes RashesO) Skin Disorders) Connective tissue disordersO) Other: Psychiatric No/ Yes Change in mood or behavior Change in sleep patternsO) Other: Immunologic/ No/ Yes AsthmaO) Hay feverO Chronic rashes Communicable DiseasesO Other: _ Allergic Signature (Person Completing Form) Date Completed Physician Signature Date FOR OFFICE USE ONLY: Initials below indicate Allergies, Additionally, the indicated elements of Section #1 have been data Medications, and Problems have been data entered as discrete entered into the CROWN System as discrete data: elements into the CROWN System. ___ Family History ___ Past Medical History ____ Past Surgical History ___ Social History Scan Folder: Ortho Intake Form Page 3 of 4 Revised 2/2/12 EFTA00311065

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Orthopaedic Clinical Intake Form MRN: 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 2/2/12 EFTA00311066

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COR p, ‘ . Christopher S. Ahmad, M.D. Ohannes A. Nercessian, M.D. Gi - % New York Orthopaedic Louis U. Bigliani, M.D. Melvin P. Rosenwasser, M.D. % & 3 . * Edwin R. Cadet, MD, Benjamin D. Roye, M.D. Ss 5 Hospital Associates Jeffrey A. Geller, M.D. David P. Roye, M.D. Justin K. Greisberg, M.D. Robert J. Strauch, M.D. Joshua E, Hyman, M.D. Peter Tang, M.D. YongJung Kim, M.D. J. Turner Vosseller, M.D. Francis Y. Lee, M.D. Michael G. Vitale,M.D. Jonathan Lee, MD. Mark Weidenbaum, M.D. William N. Levine, M.D. Nicole Baiton, NP. . William B. Macaulay, M.D. Carmela Evangelista, NP Date: APZIL [SB 26> Christopher B. Michelsen, M.D. Rachael Lyons, DPN Patient Name: DEC FREN EPSTBAI DOB: 7 MRN: 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 If You Have... You Are Responsible For... NYOHA WilL.. QO Commercial insurance Paying for services at the time of the visit. Provide you a receipt so you can file the Also known as indemnity, or “regular” claim with your carrier. insurance. QO 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 are not covered by your plan, at the time of your visit. QO Out of network PPO or HMO Paying your deductible and full charges at the time of plans the visit. OQ Regular Medicare Paying your deductible if it is not yet met, as well as any services not covered by Medicare. your plan. File the insurance claim. File the insurance claim. File the Medicare claim, as well as any claims to your secondary insurance. If you do not have secondary coverage or Medigap, you will also be asked to pay the 20% Medicare coinsurance. Obtaining a referral authorization from your primary care physician as needed. No payment is due at the time of service. If you supply our staff with a valid case number, adjuster name and phone number, no payment is necessary at the time of the visit. File the Medicaid claim. Q Worker's Compensation physician, employer information, and referral procedures. QO Uninsured or Major Medical only Paying for services at the time of the visit. Q Third Party Liability and Accident | Paying for services at the time of the visit. Victims O Personal Injury Payment for services at the time of the visit. Work with you to settle your account, by your primary insurance carrier. Cooperate with your attorney to provide copies of records and reports, (At an additional charge.) Scan Folder: Payment Policy Revised 07/1/2011 Inform you of any services not covered by Call your carrier ahead of time to verify the accident date, claim number, primary care File the claim, according to the rules stated EFTA00311067

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3) Ee’ ColumbiaDoctors The Physicians and Surgeons of Columbia University Christopher S. Ahmad, M.D. Louis U. Bigliani, M.D. Edwin R, Cadet, MD. Jeffrey A. Geller, M.D. Justin K. Greisberg, M.D. Joshua E, Hyman, M.D. YongJung Kim, M.D. Francis Y. Lee, M.D. Jonathan Lee, MD. PATIENT ACKNOWLEDGMENT OF THE NOTICE OF PRIVACY PRACTICES La \ Doceday, MD. ! acknowledge that | was provided with a copy of the Columbia University Health Christopher B, Michelsen, M.D. Sciences Notice of Privacy Practices. Ohannes A. Nercessian, M.D. Melvin P. Rosenwasser, M.D. Benjamin D. Roye, M.D. JEEE 2 EN EPSTE in) Are L i pare) es David P. Roye, M.D. " Robert J. Strauch, M.D. Patient Name Date Peter Tang, M.D. J, Turner Vosseller, M.D, ee Michael G. Vitale, M.D. Signature of patient or personal representative If personal representative, Mark Weidenbaum, M.D. Personal representative's - 7 authority to act Nicole Baiton, NP. Carmela Evangelista, NP Rachael Lyones, DPN Scan Folder: Hipaa Revised 06/29/2011 EFTA00311068

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m0) ColumbiaDoctors ‘The Physicians and Surgeons of Columbia 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. 7~ = — = Name: = FRE — Date of Birth: : MRN#: Visit Date: AP@IL (3 DO\|a. Ethnicity: Decline Response (i do not wish to answer) Hispanic or Latino Not Hispanic or Latino ood Decline Response (| do not wish to answer) American- Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or other Pacific Islander White Other gooooogod e Preferred Language: O Decline Response (| do not wish to answer) oO ARABIC Oo Other © YIDDISH Oo CHINESE Oo PERSIAN o CZECH Oo POLISH o DUTCH o PORTUGUESE oO ENGLISH Oo ROMANIAN Oo FRENCH Oo RUSSIAN o GERMAN o SIGN LANGUAGE oO GREEK oO SLOVAK oO HEBREW Oo SPANISH Oo HINDI Oo SWAHILI Oo INDONESIAN Oo TAGALOG Oo ITALIAN oO THAI Oo JAPANESE Oo TURKISH Oo KOREAN 0 URDU o MALAY Oo VIETNAMESE DO NOT SCAN THIS DOCUMENT EFTA00311069

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MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) lL , (“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 , hot 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 AOB_20122301 EFTA00311070

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TEE & OZ EPONAOD CPEOODD ONO OSPPEL ZRNC0 ! A ond x re) > 7) NI31Sd3'r SVHOHL IS @80¢00 LOO O84%%E2 S¥s000< IA areoyTeayTpoyuy) €-d SaLyvnb WOOH aay ooL9 0000-20800 } UnitedHealthcare’ Health Plan (80840) | Momber ID: Group Num Member FINANCIAL TRUST JEFFREY EPSTEIN COMPANY Payer ID Otfice: $20 UngCare: $75 UnitedHealthcare Choi DOI - 09 Uederwrtton by Undegtimatthcare insu S$ tg 4 0 WN' 10 0000-20800 IA YALYVND HOOH O34 ANYWdWO9 LSNYL TWIDN -g* ¢ This card does not quaraniee coverage. To verify benefits, view claims, or find a provider, visit the websites or call. For Members: www.myuhc.com Care24 Mental Health For Providers: www.unitedhealthcareonline.com Medical Claims: P.O. BOX 740800 ATLANTA GA 3037. x shared cosgs vaFacars Mounier Pharmacy Claims:PO BOX 1471 For Pharmacists: 800 922-15 , LEXINGTON KY 40512 EFTA00311071

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ovés201. 100 CARDIUVASC IMAG PAGE 2@1 Edison Imaging Asso. 9/20/2011 9:15:30 AM PAGE 1/001 Fax Server Advanced Cardiovascular {maging 62 East 88th St New York, NY 10128 rrone i a Steven D. Wolff, M.D,, Ph.D Director Rony Shimony 110 E 59 St Ste 6A New York. } Patient Name; EPSTEIN, JEFFREY DOB: 01/40/1953 Exam Conipleted: 09/22/2011 5:55 PM Examination LUMBAR SPINE MRI Comparison None avellable Clinical History Pain in back and legs Technique Sagittal FSE, Axial FSE, Sagittal FLAIR T1, Sagittal IR Findings There is minimal degenerative grade 1 anterolisthesis of L4 on L5. Conus ands hormally at the lower T12 level and appears intrinsically normal. There is no acute fracture. T11-T12-L2-L3 there is no focal dise herniation ot stenosis. L3-L4, there is disc bulge and facet arthrosis. L4-L5. there is anterclisthesis, there Is broad disc bulge with facet arthrosis en¢ ligamentum flavum hypertrophy. There Is severe central canal, subarticular and moderate to marked foreminal stenosis. There Is impingement of the L5 and encroachment on the exiting L4 nerves. LS-S1 there is disc bulge asymmetnic To the right with Fight greater then lef facet amnrosis. There is mila to moderate tight Subarticular stenosis with encroachment on the right S1 nerve. Impression Severe L4-L5 and to a lesser degree right-sided LS-S1 stenceis. Thank you for the courtesy of thie referral. Dictated by: Jijani, Mohammad MD Electronically Signed By: — Jani. Mohammad, MD 09/23/2011 9:14 AM Transcribed by: Jilani, Mohammad. MD on September 23, 2011 9:14 AM a ' nere EFTA00311072

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Gh ColumbiaDoctors Department of Orthopaedic Surgery ‘The Physicians and Surgeons Appointmept Scheduling Department of Columbia University Tel. April 03, 2012 Jeffrey Epstein 301 East 66th Street Suite 10b Palm Beach, FL 10065 Re: EPSTEIN,JEFFREY MRN: IDX00938430 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: “| 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. “| Medical History e¢ 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, MRI or CT scan, etc. * Medications you are currently taking. (Please bring actual bottles or containers) 1 Payment Information: Payment is due at the time of your visit. e Patient Payment Policy is enclosed for you to review and sign. ¢ Please bring your Insurance card(s). ¢ Insurance referral if applicable. [f 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. e Payment can be made using cash, check or credit card. e Charges for ancillary testing such as laboratory, radiology and other tests may be billed to you separately. ) 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. 7 ‘ Sincerely, Pre-Appointment Scheduling Department Columbia Orthopaedics Columbia University Medical Center EFTA00311073

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Herbert “Irving” Pavilion 161 Fort Washington Avenue, 2” FI New York, NY 10032 ; Between Riverside Drive and Broadway ‘ Corner of 165" St. and Fort Washington Ave. ‘i From George Washington Bridge:1 Exit onto Henry Hudson Parkway, and then onto the Riverside Drive South. Continue on Riverside Drive until 165" Street. Make left onto 165" 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 165" Street. Make right onto West 165” 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 168" Street and Broadway. Bus - M2, M3, M4, M5, M100, or BX7 Parking: Parking is available at the corner of 165” 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 2” floor reception desk to pick up the requisition before proceeding to the Radiology Department on the 1* floor. . f EFTA00311074

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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 respect 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

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to give your health plan information about your treatment in order for your health plan to pay for 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 associ- 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

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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 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 disease, 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 if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be 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

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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://www.cumc.columbia.edu/hipaa/. 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 physicians 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 New York, NY 10032 Phone: E-mail: Website: www.cumc.columbia.edu/hipaa Effective date: April 14, 2003 Revised date: October 22, 2007 EFTA00311078