SCHAFFER, SCHONHOLZ & DROSSMAN, LLP — BREAST MRI Tel: Fax: BREAST MRI APPPOINTMENT INFORMATION TIME: oS _ iS SCHEDULER: le l in office O Qa 8) USPS mail 0 At your physician's request, you have been scheduled for an MRI examination of the breast. The examination will be performed at our Breast MRI office located on the Concourse Level at 315 West 57” Street between 8" and 9” Avenue. Below, you will find important information regarding the procedure. Please read these instructions carefully and call our office at 212-755-7656 if you have any questions. PATIENT'S NAM APPOINTMENT DATE: REF PHYSICIAN: MRI PACKET PROVIDED TO PATIENT ON: * Please arrive to the MRI Office at your scheduled time so you can review your identifying documentation and prepare for the examination * Ifyou are 60 years old or over or have a history of diabetes or renal disease, a recent (within two weeks of your appointment) BUN and Creatinine blood test is required to assess renal function in association with a contrast agent which may be administered during your MRI examination. Should these results not be available at the time of your examination, a “finger-stick” laboratory screening test will be performed just prior to your MRI examination. NOTE: If you are having the MRI exam for assessment of breast implant rupture, the previous two paragraphs do not apply to you.) * Bring your completed MRI Screening sheet. = You may continue to take all medications you currently take as prescribed. * It is extremely important to bring any previous studies related to this procedure for comparison with your current examination. If you have any films related to this procedure please bring them with you. * — Also, if your Referring Physician has given you any notes that pertain to the study, please bring those with you as well, * Allow one to one and a half hours for the MRI exam. * Our Physicians will contact you within 48 hours to discuss the MRI results. A detailed medical report will be sent to your Referring Physician. BILLING PROCEDURES ao The fee for the procedure(s) that has been scheduled is: $ =< ee Please be advised that our office does not participate with any commercial insurance plans. The fee for this examination will be billed to you to the address we have on file. Please note that most insurance companies require pre-certification for this examination. We suggest that you contact your insurance carrier for information regarding pre-certification requirements so you may be reimbursed for this service according to your policy's allowances. If you have any billing questions, please call our Billing Department at 212-755-7656 Ext 17 + PLEASE SEE OTHER ATTACHMENTS FOR ADDITIONAL INFORMATION + EFTA00520767

--=PAGE_BREAK=--

The Breast MRI office is located at 315 West 57” Street between 8" and 9” Avenues - Concourse Level, Suite LL4 Transportation: e By Subway: A, B, C, D or 1 to Columbus Circle e° By Bus: M5, M6, M7, M30, M31, M57 and M104 stop nearby. Parking: ° The nearest parking facility is on 57” Street between 8" and 9" Avenue - directly across the street from our office. OE te tig NFER TR TE Ee aT RON Le Trae ae OS RL PR A ANNE RN TOR EFTA00520768

--=PAGE_BREAK=--

Schaffer, Schonholz & Drossman, LLP — Breast MRI 315 West 57" Street - Concourse Level Tel pe New York, New York 10019 Fax BREAST MRI GUIDELINES ¢ Please bring anything in writing from your referring doctor. ¢ Take all medications as prescribed. ¢ Leave all valuables at home. ¢ Allow one hour for each MRI exam scheduled. ¢ Results will be sent to your referring doctor in 2-3 business days. ¢ Please call us prior to appointment if you are pregnant or have a cardiac pacemaker, cardiac valves, implanted cardiac defibrillator, aneurysm clips, cochlear ear implants, heart stents, and retinal implants. ¢ Your appointment time includes a 15 minute registration period. If you have any questions or concerns, please call our office at fe EFTA00520769

--=PAGE_BREAK=--

yD (\e ” ; Os a K* od 488 Madison Avenue « New York, NY 10022 PRE-CERTIFICATION INFORMATION SCHAFFER, SCHONHOLZ & DROSSMAN, LLP — °° #4; poe: \alex | am aware that the MRI procedure | have scheduled may need to be pre-certified by my insurance carrier in order for me to receive full or partial reimbursement. | am aware that the pre-certification process may take several days to be completed and that it is my responsibility to initiate the process in a timely fashion. | am aware that | am responsible for the full fee as stated below. Breast MRI $ 2,200.00 © MRI Guided Breast Biopsy $ 3,600.00 3 MRI Guided Wire Localization $ 2,700.00 Patient's Signature: Y_/ Date: EFTA00520770

--=PAGE_BREAK=--

SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 Tel: New York, NY 10019 Fax: _BREAST HISTORY SCREENING SHEET. (Please print legibly, Patient's Name: Acc #: MRN: Date of Exam: Age: ~- dos: Sex: E Have you had a prior mammogram: O Yes O No Where?: Date: Have you had a recent clinical breast exam by your physician/practitioner (within the past year)? O Yes QO No Last CBE Date: CD Annual screening exam (no problems) OC Diagnostic Exam (Check allthat apply) OLeft O Right O Both or er te C NEW lumps in your breast? C 6 month follow-up exam / 1 NEW pain in your breast? © Call back examination D Abnormal discharge from nipple? =O Other changes? | Explain: Family History: Do you have a family history of breast cancer? O Yes ONo iLyes, who? Age when diagnosed? who? Age when diagnosed? Personal History: Have you ever had breast cancer? O Yes ONo When? If yes, please check the following boxes: Which breast? O Left O Right O Both What surgery? © Mastectomy O Lumpectomy (for breast cancer) Radiation therapy? O Yes O No Type of cancer? O Invasive ODCIS O Not sure Are you BRCA positive? (Breast cancer gene) O Yes ONo OC Have not been tested Surgical History: Have you ever had ANY previous breast surgery? OYes ONo If yes, please check the following boxes: Benign excision OLeft CRight QO Both When? Aspiration OLeft O Right O Both When? _ Needle biopsy O Left C Right O Both When? Breast reduction/breast lift O Yes No When? Implants O Yes O No When? implant Type O Silicone CO Saline Medical Information: Are you pregnant? O Yes O No Are you currently breast feeding? O Yes ONo Do you have monthly menstrual periods? O Yes 0 No (post menopausal) 0 No (post hysterectomy) Date of last menstrual period: Are you on hormone supplement? O Yes O No Are you on birth control? O Yes O No Personal history of any cancer other than breast cancer? O Yes ONo Explain: 00 Personal history of any other medical condition? O Yes O No Explain: ees Patient Signature: Date: Technologist initials: EFTA00520771

--=PAGE_BREAK=--

SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 Tet: New York, NY 10019 i PATIENT MEDICATION GUIDE FOR GADOLINIUM-BASED CONTRAST _. Patient Name: MRN: Contrast Type Being Administered: Wootarem {_Jeovist {__|Muttinance [_Jother: FDA The United States Food & Drug Administration requires imaging centers to share this information with patients scheduled to receive gadolinium-based contrast agents for magnetic resonance imaging. What is a GADOLINIUM-BASED CONTRAST AGENT (GBCA)? * The injection you are scheduled to receive is a prescription medicine called a gadolinium-based contrast agent (GBCA). GBCAs are injected into your vein and used with a magnetic resonance imaging (MRI) scanner. « AnMRI exam with a GBCA helps your doctor to see problems better than an MRI exam without a GBCA. « Your doctor has reviewed your medical records and determined that you would benefit from using GBCA with your MRI. What is the most important information | should know about GADOLINIUM-BASED CONTRAST AGENTS? * This injection contains a metal called gadolinium. Small amounts of gadolinium can stay in your body including the brain, bones, skin and other parts of your body for a long time (several months to years). + tis not known how GBCAs may affect you, but so far, studies have not found harmful effects in patients with normal kidneys. « Rarely patients have reported pains, tiredness, and skin, muscle or bone ailments for a long time, but these symptoms have not been directly linked to gadolinium. + There are different GBCAs that can be used for your MRI exam. The amount of gadolinium that stays in the body is different for different gadolinium medicines. Gadolinium stays in the body more after Omniscan or Optimark than after Eovist, Magnevist or MultiHance. Gadolinium stays in the body the least after Dotarem, Gadavist or ProHance. « People who get many doses of gadolinium medicines, women who are pregnant and young children may be at increased risk from gadolinium staying In the body. * Some people with kidney problems who get gadolinium medicines can develop a condition with severe thickening of the skin, muscles and other organs in the body (nephrogenic systemic fibrosis). Your healthcare provider should screen you to see how well your kidneys are working before you receive GADOLINIUM-BASED CONTRAST. Do not receive a GADOLINIUM-BASED CONTRAST if you have had a prior severe allergic reaction to it. Before receiving GADOLINIUM-BASED CONTRAST, tell us about all your medical conditions, including if you: « Have had any MRI procedures in the past where you received a GBCA. Your healthcare provider may ask you for more information including the dates of these MRI procedures. « Are pregnant or plan to become pregnant. It is not known if GADOLINIUM CONTRAST can harm your unborn baby. Talk to your healthcare provider about the possible risks to an unborn baby if a GBCA is received during pregnancy. « Have kidney problems, diabetes, or high blood pressure. * Have had an allergic reaction to dyes (contrast agents) including GBCAs. What are possible side effects of GADOLINIUM-BASED CONTRAST? * See above “What is the most important information | should know about GADOLINIUM-BASED CONTRAST AGENTS?".~ « Allergic reactions: GADOLINIUM-BASED CONTRAST can cause allergic reactions that can sometimes be serious. Your healthcare provider will monitor you closely for symptoms of an allergic reaction. Most common side effects of GBCAS: Nausea, headache, dizziness and cold feeling or burning at the injection site. Other common side effects can include: Rash, pain, vasodilation, tingling in hands or feet, and taste perversion. These are not all the possible side effects of GADOLINIUM-BASED CONTRAST AGENTS. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. General information about the safe and effective uses and ingredients of GADOLINIUM-BASED CONTRAST. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your healthcare provider for information about GADOLINIUM-BASED CONTRAST that is written for health professionals. Dotarem Eovist MultiHance Active ingredient: Gadoterate meglumine Active Ingredient: Gadoxetate disodium Active Ingredient: Gadobenale Inactive Ingredients: DOTA, water Inactive Ingredients: Caloxetate trisodium, dimegiumine t trometamol, hydrochloric acid and/or sodium Inactive Ingredient: water i — hydroxide (for pH), water ufacturer: Bracco Dia i uide appr the FDA 4/2018 Manufacturer: Bayer HealthCare Pharmaceuticals 4/2018 uide approved by the FDA 4/2018 | acknowledge that | was provided the above Information regarding Gadolinium-Based Contrast Agents. Date: Patient Signature: Witness Signature: Job Title: EFTA00520772

--=PAGE_BREAK=--

MEDICATION GUIDE DOTAREM® (doh TAH rem) (gadoterate meglumine) Injection for Intravenous use What is DOTAREM? * DOTAREM is a prescription medicine called a gadolinium-based contrast agent (GBCA). DOTAREM, like other GBCAs, is injected into your vein and used with a magnetic resonance imaging (MRI) scanner. « AnMRI exam with a GBCA, including DOTAREM, helps your doctor to see problems better than an MRI exam without a GBCA. * Your doctor has reviewed your medical records and has determined that you would benefit from using a GBCA with your MRI exam. What is the most important information | should know about DOTAREM? * DOTAREM contains a metal called gadolinium. Small amounts of gadolinium can stay in your body including the brain, bones, skin and other parts of your body for a long time (several months to years). ¢ — Itis not known how gadolinium may affect you, bul so far, studies have not found harmful effects in patients with normal kidneys. « Rarely patients have reported pains, tiredness, and skin, muscle or bone ailments for a long time, but these symptoms have not been directly linked to gadolinium. «There are different GBCAs that can be used for your MRI exam. The amount of gadolinium that stays in the body is different for different gadolinium medicines, Gadolinium stays in the body more after Omniscan or Optimark than after Eovist, Magnevist or MultiHance. Gadolinium stays in the body the least after Dotarem, Gadavist or ProHance. * People who get many doses of gadolinium medicines, women who are pregnant and young children may be at increased risk from gadolinium staying in the body. * Some people with kidney problems who get gadolinium medicines can develop a condition with severe thickening of the skin, muscles and other organs in the body (nephrogenic systemic fibrosis). Your healthcare provider should screen you to see how well your kidneys are working before you receive DOTAREM. Do not receive DOTAREM if you have had a severe allergic reaction to DOTAREM. Before receiving DOTAREM, tell your healthcare provider about all your medical conditions, including If you: * have had any MRI procedures in the past where you received a GBCA. Your healthcare provider may ask you for more information including the dates of these MRI procedures. * are pregnant or plan to become pregnant. It is not known if DOTAREM can harm your unborn baby. Talk to your healthcare provider about the possible risks to an unborn baby if a GBCA such as DOTAREM is received during pregnancy. have kidney problems, diabetes, or high blood pressure. have had an allergic reaction to dyes (contrast agents) including What are possible side effects of DOTAREM? « See “What is the most important information | should know about DOTAREM?” * Allergic reactions. DOTAREM can cause allergic reactions that can sometimes be serious. Your healthcare provider will monitor you closely for symptoms of an allergic reaction. The most common side effects of DOTAREM include: nausea, headache, pain, or cold feeling at the injection site, and rash. These are not all the possible side effects of DOTAREM. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective uses of DOTAREM. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your healthcare provider for information about DOTAREM that is written for health p ofessionals. What are the ingredients in DOTAREM? Active ingredient; gadoterate meglumine Inactive ingredients: DOTA, water for injection Manufactured by: Catalent and Recipharm (vials) for Guerbet For more information, go to or call Giieereeiies Administration. Rev. 4/2018 GBCAs. This Medication Guide has been approved by the U.S. Food and Drug EFTA00520773

--=PAGE_BREAK=--

SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 New York, NY 10019 Medical Record #: Referring Dr.: Patient Name: Date of Exam: Date of Birth: mr Certain implants, devices or objects may be hazardous andlor | may interfere with ‘your MRI srocedure. Do not enter the MRI exam room if you have questions or concern regarding an implant, device or object. 2 2 Consult the MRI Technologist BEFORE entering the MRI exam room. ONO Injury to your eye involving motel CONO Any metallic fragment or foreign body ONO Aneurysm clip(s) ONO Cardiac pacemaker ONO Implanted cardioverter defibrillator (ICD) ONO Electronic implant or device ONO Magnetically-activated implant or device Neurostimulation system Spinal cord stimulator Internal electrodes or wires Bone growth / bone fusion stimulator Cochlear, otologic or other ear implant Insulin or other infusion pump Implanted drug infusion device Any type of prosthesis (eye, penile, etc.) Heart valve prosthesis Eyelid spring or wire Artificial or prosthetic limb Metallic stent, filter or coil Shunt (spinal or intraventricular) Vascular access port and/or catheter Radiation seeds or implants Swan-Ganz or thermodilution catheter Medication patch (Nicotine, Nitroglycerine, etc.) Wire mesh implant Tissue expander (breast or other) Surgical staples, clips or metallic sutures Joint replacement (hip, knee, etc.) Bone/joint pin, screw, nail, wire, plate, etc. IUD, diaphragm or pessary Other implant: Dentures or partial plates Tattoo or permanent makeup Body piercing jewelry Hearing aid (remove before entering exam room) Breathing problem or motion disorder ONO Claustrophobia ~ IMPORTANT INSTRUCTIONS Mark on the figure below the location of any implant or metal inside of or on your body Lerr CLEFT Remove ALL metallic objects in the dressing room, including: ~ hearing aids dentures and partial plates cell phone and pagers keys eyeglasses hair pins and barrettes jewelry and watch, including body piercing jewelry - safety pins money clip and coins cone. cards, bank cards and magnetic strip cards rocket knife nail clipper clothing with metal fasteners and metallic threads steel-toed boots/shoes tools EFTA00520774

--=PAGE_BREAK=--

* If a mother desires, she may refrain from breastfeeding for 24 hours and discard milk after gadolinium injections. Are you: Pregnant? Yes ONo Possibly Pregnant? OYes ONo Breast Feeding? O Yes ONo Date of Last Menstrual Period: * MRI Radiofrequency has the potential to cause tiss Alert the technologist immediately if you notice any heating sensations during your MRI scan. * A small number of patients have experienced transient skin irritation, ling, bruising or heating sensations at the site of piercings, cosmetic implants, tattoos and permanent makeup in association with MR procedures. individuals with these items should inform the technologist so precautions can be taken. : -MEDICAL HISTORY Why are you having this test done? What is the reason? | List surgeries you have had and date of surgery: Where/What area is the problem? Body part involved? Do you have or ever had cancer? 0 Yes 0 No Which side (left/righVupper/lower)? If yes: What Type — Where (body part) When did your symptoms start? Describe the problem it is giving you. What type of treatment did you receive and when? Did you injure the area of interest? O Yes O No Check all that are applicable to your symptoms: If yes, describe: O Acute (present or a severe and intense degree) List all medications you are taking and what they're for: O Chronic (persisting a long time / constantly recurring) OIntermittent 0 Transient (lasts only a short time) C Primary Issue © Secondary due to another issue | Have you been in the hospital within the last week? List any tests you had at other facilities for this problem: | OYes O No _ if yes, describe below: Ex: Lab, X-Ray, Upper GI, BE, Ultrasound, MRI, CT Test - Date - Where Have you ever experienced any problem related to a previous MRI procedure or MRI contrast? 0 Yes O No OYES ONO Kidney disease or kidney injury OYES ONO Kidney surgery, transplant, single kidney OYES ONO Kidney tumor or cancer OYES ONO Diabetes OYES ONO Are on dialysis OYES ONO Chemotherapy in the past 3 months OYES ONO Take medication for hypertension (follow local protocol) OYES ONO Pastallergic reaction to gadolinium or lodine contrast OYES ONO Asthma or allergy CONTRAST CONSENT Due to your medical history, or as requested by your physician, an injection of MRI gadolinium contrast may be necessary to aid the radiologist in evaluating your MRI scan. The Food and Drug Administration has approved this agent. A very small percentage of patients receiving gadolinium may develop a headache or experience mild nausea. Rarely, local inflammation may occur at the injection site. © | CONSENT to having Gadolinium contrast as needed. (Check box if you agree to contrast) 0) | DECLINE having e Gadolinium contrast injection at this time. (Check box if you disagree to contrast) | atlest that the information on this form is correct to the best of my knowledge, | have read and understand the contents of this form and had the opportunity to ask questions regarding the MR procedure | am about to undergo. | understand that emergency or follow-up care, if needed, Is the direct financial responsibility of the patient receiving additional 3rd party services (ambulance transport to a hospital, 911 call, medical care, etc.). Patien/Guardian Signature: Date: FOR STAFF USE: Screening Performed By: OMR Technologist ONurse O Radiologist D0 Other: Staff Signature: Print Name: EFTA00520775

--=PAGE_BREAK=--

SCHAFFER, SCHONHOLZ & DROSSMAN, LLP Tax ID # 13-198-5544 MRI PROCEDURES PRE-CERTIFICATION INFORMATION Most insurance companies require pre-certification for MRI examinations. Below, you will find the procedure codes your insurance carrier will need to pre- certify your MRI. Please note that it is the patient's responsibility to initiate the pre-certification process by calling the insurance carrier and notifying them of the procedure to be performed. Your insurance company pre-cert specialist may also request to speak with your Referring Physician during the pre- certification process. Should they have any additional questions, please have them contact our Billing Department 2 ne 17. Thank you. DESCRIPTION CPT-4 CODE DESCRIPTION eeUREES 2 5| MRI BREAST - UNILAT w/wo CONTRAST and 3D RECONSTRUCTION and ANALYSIS ON INDEPENDENT WORKSTATION | $2100 | [Soe eee Payee CPT-4 CODE MRI GUIDED BIOPSY, BREAST, WITH OR WITHOUT PLACEMENT OF CLIP AND IMAGING OF THE BIOPSY SPECIMEN, PERCUTANEOUS, FIRST LESION TOTAL FEE: 19086 MRI GUIDED BIOPSY, BREAST, + EACH ADDITIONAL SITE WITH OR WITHOUT CLIP PLACEMENT NOTE: Breast biopsies require that we send the tissue specimen obtained during the procedure to a pathologist for microscopic examination and reporting. The specimen obtained will be sent to Mount Sinai Pathology Associates or to the University of Pennsylvania Surgical Pathology Department. New York State Law (Section 394-E) requires that clinical laboratories bill patients directly. The lab processing your specimen(s) will bill you separately for their services. If you have any questions regarding the laboratory billing, please contact: Mt Sinai Pathology Associates: 1-800-542-5760 University of Pennsylvania Pathology: Updated 05/30/19 EFTA00520776