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Home My WebLink AboutExhibit 5Mercy Medical Development d/b/a Mercy Outpatient Center (Second -highest ranked firm) RFP Number: 220240,1 Title: Request for Proposals for Physical Examination Services Proposer: Mercy Medical Development D/B/A Mercy Outpatient Center 3641 South Miami Avenue Miami, Florida 33133-4205 FEIN: 59-2789194 Contact and Contract Liaison: Reuben J. Camp III, MSN, RN Senior Director, Mercy Outpatient Services Bayside Pavilion 3641 South -Miami Avenue Miami, Florida 33133-4205 Office: 305.285.2624 Fax: 305.860.2614 scamp@mercymiami.org RFP Number: 220240,1 Title: Request for Proposals for Physical Examination Services Proposer: Mercy Medical Development D/B/A Mercy Outpatient Center 3641 South Miami Avenue Miami, Florida 33133-4205 FEIN: 59-2789194 Contact and Contract Liaison: Reuben J. Camp III, MSN, RN Senior Director, Mercy Outpatient Services Bayside Pavilion 3641 South Miami Avenue. Miami, Florida 33133-4205 Office:305.285.2624 Fax: 305.860.2614 scamp@mercymiami.org 0 t utile CR t RFP Number: 220240,1 Title: Request for Proposals for Physical Examination Services Proposer: Mercy Medical Development D/B/A Mercy Outpatient Center 3641 South Miami Avenue Miami, Florida 33133-4205 FEIN: 59-2789194 Contact and Contract Liaison: Reuben J. Camp III, MSN, RN Senior Director, Mercy Outpatient Services Bayside Pavilion 3641-South Miami Avenue- - -- - Miami, Florida 33133-4205 Office: 305.285.2624 Fax: 305.860.2614 scamp@mercymiami.org TABLE OF CONTENTS Section 1 Cover Sheet Section 2 Table of Contents Section 3 Executive Summary ■ Executive Summary signed and dated: w Certification Statement • Certification e Fee Proposal Section 4 Section 5 Professional Experience O Organizational History and Structure ■ List of Principals and Directors ▪ Credentials of Medical Professionals ▪ HIPPA Joint Notice of Privacy Practices and Sample Forms ▪ List of Clients o List of Clients Who Discontinued Services Proposer's Facility and Location ▪ Facility Location and Description ■ Services Performed ▪ Directions Section 6 Fee Proposal Section 7 Trade Secrets Execution to Public Records Executive Summary: Mercy Hospital has been serving the healthcare needs of South Florida for over 50 years. As a comprehensive healthcare facility, Mercy offers a full range of services to the residents of Miami -Dade county and surrounding communities. A 473-bed acute care facility, Mercy Hospital is accredited by Joint Commission. Mercy is affiliated with over 700 physicians representing 27 medical specialties. Its Centers of Excellence include: The Heart Center at Mercy Hospital, the Miami Cancer Center at Mercy Hospital, Minimally invasive Surgical Institute and the Orthopaedic Institute at Mercy Hospital. As Miami -Dade County's only Catholic hospital, Mercy Hospital is sponsored by the Sisters of St. Joseph of St. Augustine, Florida and is part of Catholic Health East. Since its inception in 1950, Mercy Hospital has maintained its reputation for excellence while following the Catholic tradition of caring for God's people and providing spiritual support. Mercy Hospital .is dedicated to providing excellent medical care, while remaining true to its mission of caring for the physical and spiritual needs of all the people it serves. Mercy Outpatient Center (MOC) is recognized as one of the largest diagnostic centers in South Florida. MOC is accredited by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and provides unmatched outpatient services and clinical quality. In October 2003 Mercy Outpatient Center relocated to the four-story 90,000 square foot Bayside Pavilion complex, the latest addition to the Mercy campus. A recent winner of the South Florida Business Journal 2004 Excellence in Healthcare Award for Facility Expansion & Growth, the Pavilion was built with a vision to better serve the community by consolidating existing services, offering the latest in digital technology, while improving access offered at the Mercy Outpatient Center, The Pavilion also houses the Bayside Ambulatory Center for Surgery and Digestive Disorders, a fully -equipped Ambulatory Surgery Center that performs endoscopy and many outpatient surgical programs. When today's demanding healthcare consumer visits Mercy Outpatient Center, they will find patient privacy as one of its highest priorities and an unparalleled focus on patient service and satisfaction. Using state-of-the-art technologywith interpretations by board certified radiologists and nuclear cardiologists, Mercy Outpatient Center's services include: Women's Center (Mammography, Breast Biopsy, DEXA); Nuclear Imaging Studies; CT Scan; PET/CT; All Digital Diagnostic Radiology; Ultrasound; Complete Laboratory Services (all types of drug testing); Center for Health Promotion; Executive Physicals; international Travel Clinic. Mercy Outpatient Center is home to a wide array of services designed to fulfill almost any outpatient need: Comprehensive Cardiovascular Diagnostic and Rehabilitative Services; Pre -Employment Physical Exams; Wellness Physicals; and special immunization programs performed through the Center for Health Promotion, The state-of-the-art Bayside Pavilion includes a conference center with top -of -the -line audio visual equipment, lounges with plasma TVs and a cafe, among other amenities. The services proposed will be provided by: Mercy Outpatient Center Center for Health Promotion Bayside Pavilion 3641 South Miami Avenue i, Florida 33133-4205 cv f ate Contact Person at Mercy Outpatient Center Reuben J. Camp III, MSN, RN Senior Director, Mercy Hospital Outpatient Services Tel: 305.285.2624 Fax: 305.860.4614 Reuben 1. Camp 19J;'MSN, RN, Senior Director Certification Statement Please quote on this form, if applicable, net prices for the item(s) listed. Return signed original and retain a copy for your files. Prices should include all costs, including transportation to destination. The City reserves the right to accept or reject all or any part of this submission. Prices should be firm for a minimum of 180 days following the time set for closing of the submissions. In the event of errors in extension of totals, the unit prices shall govern in determining the quoted prices. We (I) certify that we have read your solicitation, completed the necessary documents, and propose to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein. The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations, or debarred or suspended as set in section 18-107.or_ Ordinance No. 12271. . All exceptions to this submission have been documented in the section below (refer to paragraph and section). EXCEPTIONS: We (I) certify that any and all information contained in this submission is true; and we (I) further certify that this submission is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a submission for the same materials, supplies, equipment, or service, and is in all respects fair and without collusion or fraud. We (I) agree to abide by all terms and conditions of this solicitation and certify that I. am authorized to sign this submission for the submitter. Please print the following and sign your name: /iif'Csakdi' / :6e(/e.—/o�rrr�r�� SUPPLIER NAME: ✓- ADDRESS. 3tp ! <34, v r/) /2 ) ra 4,u PHONE: •505— a FAX' 3o,r- D' St 6/ V ENTAIL: c'•u r' ��r'�� /' 'et-i».1BEEPER: SIGNED BY: TITLE: i//' (.6irrrss J FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM SHALL DISOUALTFY THIS BID. Page 2 of 41 Certifications Legal Name of Firm: / �/% / j / L / 1 4�e-�/ /�l�%ca- ✓�/p>E'��te;)� c7164- yPlCra7 t_/v?`/,4,71,; Entity Type: Partnership, Sole Proprietorship, Corporation, etc. Or pee, a=7ie) Year Established: Office Location: City of Miami, Miami -Dade County, or Other amity OF fir)4te_ a ee.i' Occupational License Number: - Occupational License Issuing Agency: i ��ePT d F �c ✓ vim_ . Occupational License Expiration Date: Respondent certifies that (s) he has read and understood the provisions of' City of Miami Ordinance No. 10032 (Section} 5;105 of the City Code) pertaining to the implementation of a "First Source Hiring Agreement.": Yes r No) Do you expect to create new p ons in your company in the event your company was awarded a Contract by the City? (Yes or No In the event your answer to question above is yes, how many new positions would you create to perform this work? Al A Please list the title, rate of pay, summary of duties, number of positions, and expected length or duration of all new positions which might be created as a result of this award of a Contract. Page 3 of 41 (City- r.i-Th GLENN MARCOS CARLOS A. MIGOYA ChiefProcurement Officer City Manager ADDENDUM NO. 1 RFP No. 220240 July 19, 2010 Request for Proposals (RFP) for Physical Examination Services -TO: ALL PROSPECTIVE PROPOSERS: The following changes, additions, clarifications, and deletions amend the RFQ documents of the above captioned RFQ, and shall become an integral part of the Contract Documents. Words and/or figures stricken through shall be deleted. Underscored words and/or figures shall be added. The remaining provisions are now in effect and remain unchanged. Please note the contents herein and reflect same on the documents you have on hand. Section A. 2. Laboratory Work-Uo, of the City's Medical Protocol has been amended as shown below. Prospective Proposers shall refer to the enclosed revised City of Miami Medical Protocol. 2. LABORATORY WORK -UP a Complete Blood Count (CBC), with Differential b. Diochcmiatry Profile 2 Comprehensive Metabolic Panel,— Comolotc Lipid i'rafilc with= io: , any c. Complete Lipid Profile with ratios • d. TSH e. RPR f. Urinalysis (Microscopic) g- EKG (12 lead with rhythm strip) shall be interpreted by a cardiologist certified by the American Board,of Internal Medicine. h. Cardiovascular Stress Test, shall be performed by a - 7-Cardiologist --(Police— -Officer, - -Police - Auxiliary -Reserve, Detention Officer, and Firefighter) Page 1 City of Miami, Florida Physical Examination Services RFP 223228 4. EYE TEST The acuity test should screen for both near and for distance acuity on a scientifically accurate instrument that checks for keenness of vision, depth perception, balance of eye muscles, and the ability to differentiate colors. Examination should be conducted with and without corrective lenses. There are specific vision requirements for Police Officer, Police Auxiliary/Reserve, Detention Officer, Public Service Aide (PSA) and Firefighter applicants. Requirements are as follows: Police Officer, Police Auxiliary/Reserve, Detention Officer, and Public Service Aide (PSA) Vision Requirements:. 20/50 each eye., separately, without corrective lenses of any kind - including contact lenses; With glasses, each eye should be corrected to 20/30 (NO CONTACT LENSES ALLOWED). Firefighter Vision Reauirements: Far Visual acuity shall be at least 20/40 binocular, corrected with contact lenses or spectacles. Far visual acuity uncorrected shall be at least 20/100 binocular for wearers of hard contacts or spectacles. 1fl 5. AUDIOLOGICAL CHECK: Will test the normal hearing range, 500 to 4000 HERTZ, using high quality equipment. Provide written interpretation of results. PHASE II A. PHYSICAL EXAMINATION BY: Inspection, Palpation Percussion, Auscultation Must be performed by Board Certified Physician To include the following: Vital signs - - TPR, Blood pressure (both arms) Height Weight General Appearance -Head,-scalp,- face Neck (thyroid, lymphs, vessels) Endocrine system Eyes (fundi, focus) general Ocular motility Pupils (equality and reaction) Ears (internal and external canals and cerumen,) 0 0 City of Miami, Florida Physical Examination Services RFP 223228 Ear drums (perforation) Nose (sinuses) Mouth (tongue, teeth, and gums) Throat (condition of tonsils) Lungs, chest (OPTIONAL - include breasts; PHYSICIAN WILL OFFER TO PERFORM BREAST EXAMINATION) Heart (thrust, size, rhythm, sounds) Abdomen, Viscera (check for hernias) -EVALUATION BY INSPECTION, PALPATION, PERCUSSION & AUSCULTATION) External Genitalia - EVALUATION BY INSPECTION, PALPATION, PERCUSSION & AUSCULTATION) ANUS AND RECTUM EVALUATION BY VISUAL INSPECTION FOR HEMORRHOIDS & FISSURES. Upper extremities (strength, range of motion) Lower extremities (strength, range of motion) Vascular System (varicosities, etc.) Spine, -other • musculoskeletal Skin (scars, rashes,) lymphatics Mental Status, memory, orientation, judgment, affect Neurological Equilibrium B. Additional/Optional items - required for Police Officer, Public Service Aide (PSA), Police Auxiliary/Reserve, , Detention Officers, Firefighters_, Crime Scene Investigator, and Property Specialist ADDITIONAL 1. Chest X-ray (SWORN POLICE AND FIRE) Anterior/posterior and lateral views. Provide written interpretation of results. Deliver results to the Department of Employee Relations within 72 hours. 2. HIV Testing and Counseling required for Firefighter, Crime Scene Investigator, and Property Specialist applicants/employees (NOTE: These applicants/employees have the option to decline HIV Testing) Consent forms signed by the applicant/employee will be provided at the time of the physical examination. All HIV test results must be provided to the City of Miami, Department of Employee Relations in a sealed envelope and marked CONFIDENTIAL. 3. Hepatitis A, B, and C Screening required for Firefighter,- Police -Officer, -Crime Scene Investigator, - and Property Specialist applicants/employees (NOTE: These applicants/employees have the option to decline HIV Testing). Consent forms signed by the applicant/employee will be provided at the time of the ( physical examination. All HIV test results must be City of Miami, Florida Physical Examination Services RFP 223228 provided to the City of Miami, Department of Employee Relations in a sealed envelope and marked CONFIDENTIA.L. OPTIONAL 1.Back X-ray (requested by City as needed) Provide two views of the back; lumbo-sacral spine and pelvis. Provide written inte.Loretation of results from a Radiologist. 2. Pulmonary Function Test (requested by City as needed) Provide three (3)--valid tracings- of a forced vital capacity from which the Forced Expiratory Volume in one second can be delivered.. 3. Blood Type and Rh Typing (requested by City as needed) 4.Rubella Titer (requested by City as needed) 5.Rubella Immunization (requested by City as needed) 6. Tetanus vaccine (requested by City as needed) 7. Review and provide written interpretation and/or medical resume of employee/applicant medical records from another agency. Line: 1 Description: Employment and Promotional Physical Examinations for Non Sworn Classifications Line: 1.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.2 Number of Units: 425 Total: $ /J' 5/o: Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ r g- Line: 1.3 Number of Units: 600 Total: $ /p.' Description: Additional/Optional Examination Components: Back X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ / 75 Line: 1.4 Number of Units: 5 Total: $ Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ / 35 - Number of Units: 50 Total: $ (7 i 7-SO Page 4 of 41 Line: 1.5 Description: Additional/Optional Examination Components: EKG (12 lead) Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.6 Number of Units: 425 Total: $ Jr j 3-15 Description: Additional/Optional Examination Components: Rubella Titer Category: 94874-50 Unit of Measure: Each Unit Price: $ oZS Line: 1.7 Number of Units: 5 Total: $ l.? �`— Description: Additional/Optional Examination Components: Rubella Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.8 Number of Units: 5 Total: $ 7Z9 Description: Additional/Optional Examination Components: Review of Miscellaneous Medical Records Category: 94874-50 Unit of Measure: Each Unit Price: $ oZ Number of Units: 5 c3� Total: $ Page 5 of 41 Line: 1.9 Description: Additional/Optional Examination Components: Hepatitis A, B, and C Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.10 Number of Units: 25 Total: $ /i /07-5 Description: Additional/Optional Examination Components: HIV Testing & Counseling - ELISA Test Category: 94874-50 Unit of Measure: Each Unit Price: $ JCS Number of Units: 25 Line: 1.11 Total: $ Description: Additional/Optional Examination Components: HIV Testing & Counseling - Western Blot Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.12 Number of Units: 25 Total: $ // Description: Additional/OptionaI Examination Components: HIV Testing & Counseling - Pre Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 25 Total: $ 17 `� Page 6 of 41 Line: 1.13 Description: Additional/Optional Examination Components: HIV Testing & Counseling - Post Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ �S Line: 1.14 Number of Units: 25 • 00 Total: $ S5 Description: Additional/Optional Examination Components: HIV Testing & Counseling - Measles, Mumps, Rubella Immunization` Category: 94874-50 Unit of Measure: Each Unit Price: $ /55 Line: 1.15 Number of Units: 5 Total: $ 65- Description: Additional/Optional Examination Components: HIV Testing & Counseling - Tetanus Vaccine ciL D Category: 94874-50 Unit of Measure: Each Unit Price: $ 7 Line: 2 ©c� Number of Units: 5 Total: $ Description: Employment Physical Examinations for Firefighters (Examination shall be conducted pursuant to current NFPA 1582 Guidelines and City of Miami Medical Protocols) Line: 2.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Page 7 of 41 Unit Price: $5 ("0 Number of Units: 60 Total: $ d /,. o 0 Line: 2.2 Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ /3S Number of Units: 60 Line: 2.3 Total: $ Description: AdditionallOptional Examination Components: EKG Category: 94874-50 Unit of Measure: Each Unit Price: $ / 3� Line: .2.4 Number of Units: 60 Total: $ Description: AdditionallOptional Examination Components: Back X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.5 oa Number of Units: 1 Total: $ / > S Description: AdditionallOptional Examination Components: Cardiovascular Stress Test Category: 94874-50 Unit of Measure:: Each Unit Price: $ "It Number of Units: 60 Total: $ Page 8 of 41 Line: 2.6 Description: Additional/Optional Examination Components: HIV Testing & Counseling - ELISA Test Category: 94874-50 Unit of Measure: Each Unit Price: $ J� 5 Line: 2.7 Number of Units: 60 Total: $ 02 i /01) Description: AdditionallOptional Examination Components: HIV Testing & Counseling - Western Blot Category: 94874-50 Unit of Measure: Each Unit Price: $ 5` Line:.2:8 Number of Units: 60 Total: $ d /O D Description: Additional/Optional Examination Components: HIV Testing & Counseling - Pre Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ �5 Line: 2.9 Number of Units: 60 Total: $ o2 r ( Description: Additional/Optional Examination Components: HIV Testing & Counseling - Post - Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 60 Total: $ 02/ %—r) Page 9 of 41 Line: 2.10 Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ / g Line: 2.11 Number of Units: 60 Total: $ /i D 8 Description: Additional/Optional Examination Components: Hepatitis A, B and C Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ 177 Line: 3 Number of Units: 60 Total: $ 2 i �d Description: Employment Physical Examinations for Police Officers (Examination shall be conducted pursuant to current California Peace Officer Standards and City of Miami Protocol) Line: 3.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Unit Price: $ 3 C� Line: 3.2 Number of Units: 60 Total: $ (D Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Page 10 of 41 Unit of Measure: Each Unit Price: $ /3S Line: 3.3 Number of Units: 60 Total: $ / 6-0 Description: Additional/Optional Examination Components: EKG Category: 94874-50 Unit of Measure: Each Unit Price: $ /3 Line: 3.4 Number of Units: 60 - Total: $ Fi /" Description: Additional/Optional Examination Components: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ '7L Line: 3:5 Number of Units: 60 Total: $ 425r Soo Description: Additional/Optional Examination Components: Back X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ / 75- Line: 3.6 UD Number of Units: 1 Total: $ / 7S Description:AdditionaIOptional Examination Components: Hepatitis A, B, and-C Screening • Category: 94874-50 Unit of Measure: Each Unit Price: $ �f-5 Number of Units: 60 Total: $ a / 5-0 U Page 11 of 41 Line: 3.7 Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 3.8 Number of Units: 60 Total: $ /i d FU Description: Additional/Optional Examination Components: Pulmonary Function Category: 94874-50 Unit of Measure: Each Unit Price: $ 75— Line: 3.9 Number of Units: 1 Total: $ 76 o0 Description: Additional/Optional Examination Components: Blood Type & Rh Typing Category: 94874-50 Unit of Measure: Each Unit Price: $ / Line: 3.10 Number of Units: 1 Total: $ 4 -o Description: AdditionaUOptional Examination Components: Rubella Titer Category: 94874-50._ .__ Unit of Measure: Each Unit Price: $ 02.7 Number of Units: 1 Total: $ 05 Page I2 of 41 Line: 3.11 Description: Additional/Optional Examination Components: Rubella Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 3.12 Number of Units: 1 Total: $ / 6 ✓ Description: Additional/Optional Examination Components: Review & Provide Written Interpretation of Medical Records Category: 94874-50 Unit of Measure: Each Unit Price: $ e225-- Line: 4 Number of Units: 1 Total: Description: Return to Work Physical Examinations for all Classifications Line: 4.1 Description: Return to Work Physical Examinations Category: 94874-50 Unit of Measure: Each Unit Price: $ �S Number of Units: 400 Total: $ 5 4 Page 13 of 41 Organizational History and Structure On the 18th of December, 1950, the doors of Mercy Hospital opened to all those who needed medical care. Today Mercy Hospital ranks as the outstanding Catholic health care institution in South Florida, owned and operated by the Sisters of St. Joseph of St. Augustine. The second half of the 1980's saw continued growth in services, especially the development of outpatient services. Under the leadership of John Matuska, former President and CEO of Mercy Hospital, the corporate structure of Mercy was redesigned to create SSJ Mercy Health Systems; - Inc. Although Mercy Hospital continued to be the heart of the Health System, the opening of the Mercy Outpatient Center, the Magnetic Imaging, Center, the Hyperbaric Chamber, increased Mercy's capability to provide convenient and efficient outpatient diagnostic and treatment procedures. In February 2003, Mercy became a member of Catholic Health East {CHE), one of the country's largest health care systems. The Sisters of St. Joseph of St. Augustine, the Congregation that operates Mercy Hospital, joined with CHE's Sponsors Council. The Sponsors Council is the CHE governance organization, comprised of the presidents of each of the sponsored religious communities. Catholic Health East is comprised of 35 hospitals and numerous behavioral health and residential facilities in ten states from Maine to Florida. In 2010, under the leadership of Manuel P. Anton III, MD, President and CEO of Mercy, the System provides more dynamic opportunity for greater diversification of services. Mercy Hospital is better positioned to meet the challenges of today's health care environment. Mercy Outpatient Center's Center for Health Promotion has provided medical services for the City of Miami for the past twenty years. The Center's physicians and nursing staff are extremely knowledgeable and conversant with the current NFPA 158 medical requirements for firefighters and the 2010 California Commission on Peace Officers Standards for Physical Examinations. In addition, Mercy Outpatient Center provides physical exams for other municipalities including City of West Miami, the Archdiocese of Miami, and EHE International. o Mercy Hospital is the recipient of the American Nurses Credentialing Centers prestigious Magnet award for excellence in nursing services (2010). a Mercy Hospital was named in U.S. News America's Best Hospitals 2009-2010. o Recipient of American Society for Bariatric Surgery Center for Excellence Award. • Mercy Hospital and Holy Cross Hospital announced that a new study ranks both hospitals' clinical quality among the top five percent in the nation. The study by HealthGrades, the leading independent healthcare ratings organization, analyzed patient outcomes at each of the nation's 5,000 non-federal hospitals over the years2006, 2007 and 2008 and named hospitals in the top five percent as HealthGrades Distinguished Hospitals for Clinical ExcellenceTM. • Mercy Hospital's cancer program has received a three-year re -accreditation and five commendations from the American College of Surgeons' prestigious Commission on Cancer. Only 25 percent of all U.S. hospitals are approved by the Commission on Cancer and 32 are approved as a network. 2010 NOT -FOR -PROFIT C'�IPORATION ANNUAL REPOF ) FILED Mar 04, 2010 DOCUMENT# N09556 Secretary of State Entity Name: MERCY MEDICAL DEVELOPMENT, INC. `Current Principal Place of Business: New Principal Place of Business: 3663 SOUTH MIAMI AVENUE MIAMI, FL 33133 US Current Mailing Address: New Mailing Address: % LEWIS W FISHMAN 9130 S DADELAND BLVD #1121 MIAMI, FL 33156 FEI Number: 58-2788194 FE Number Applied For ( FEI Number Not Applicable ( ) Certificate of Status Desired ( ) Name and Address of Current Registered Agent: Name and Address of New Registered Agent: FISHMAN, LEWIS W TWO DATRAN CENTER, SUITE 1121 _ .91.30.S. DADELAND BLVD..._...,._ _ .. _.. _ - _ _ ....__.__ ............ MIAMI, FL 33155 US The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida. SIGNATURE: Electronic Signature of Registered Agent Date OFFICERS AND DIRECTORS: Title: D Name: JOHNSON, JOHN C ddress: 3663 SOUTH MIAMI AVE 'ty-St-Zip: MIAMI, FL 33133 Title: TD Name: GUZMAN, MARILUZ Address: 3663 SOUTH MIAMI AVE City -St -Zip: MIAMI, FL 33133 T1tIe: CD Name: HAZEL, JOHN Address: 3663 S MIAMI AVE City -St -Zip: MIAMI, FL 33133 I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears above, or on an attachment with all other like empowered. C `- . GNATURE: JOHN HAZEL CD 03/04/2010 Electronic Signature of Signing Officer or Director Date www.sunbiz.org - Department of State Page 1 of 2 Home Contact Us E-Filing Services Document Searches Forms Help Previous on List Next on List Events Name History Return To List Detail by Entity Name Florida Non Profit Corporation MERCY MEDICAL DEVELOPMENT, INC. Filing Information Document Number N09556 FEI/EIN Number 592789194 Date Filed 05/24/1985 State FL Status ACTIVE Last Event AMENDED AND RESTATED ARTICLES Event Date Filed 11/21/2003 Event Effective Date NONE Principal Address 3663 SOUTH MIAMI AVENUE MIAMI FL 33133 US Changed 04/11/2003 Mailing Address % LEWIS W FISHMAN 9130 S DADELAND BLVD #1121 MIAMI FL 33156 Changed 05/22/1989 Registered Agent Name & Address FISHMAN, LEWIS W TWO DATRAN CENTER, SUITE 1121 9130 S. DADELAND BLVD. MIAMI FL 33156 US Address Changed: 05/22/1989 Officer/Director Detail Name & Address Title D JOHNSON, JOHN C 3663 SOUTH MIAMI AVE MIAMI FL 33133 Title TD GUZMAN, MARILUZ 3663 SOUTH MIAMI AVE Entity Name Search Submit http://www.sunbiz.org/scripts/cordet.exe?action=DETFIL&inq_doc_number=N09556&in _came... 7/26/2010 www.sunbiz.org - Department of ,` State i\1 MIAMI FL 33133 Title CD HAZEL, JOHN • 3663 S MIAMI AVE MIAMI FL 33133 Annual Reports Report Year Filed Date 2008 02/04/2008 2009 02/13/2009 2010 03/04/2010 Document Images 03/04/2010 — ANNUAL REPORT 02/13/2009 — ANNUAL REPORT 02/0412008=-ANNUAL-REPORT - 02/23/2007 -- ANNUAL REPORT 01/31/2006 -- ANNUAL REPORT 03/14/2005 -- ANNUAL REPORT 02/26/2004 -- ANNUAL REPORT 11/21/2003 -- Amended and Restated Articles (_ 04/11 /2003 -- Amended and Restated Articles "- ''01/27/2003 -- ANNUAL REPORT 12/16/2002 — Amendment 03/06/2002 — ANNUAL REPORT 02/06/2001 — ANNUAL REPORT 03/21/2000 -- ANNUAL REPORT 04/07/1999 -- ANNUAL REPORT 02/01/1999 -- Amended and Restated Articles 03/31/1998 — ANNUAL REPORT 02/13/1997 -- ANNUAL REPORT 02/16/1996 — ANNUAL REPORT 02/07/1995 — ANNUAL REPORT View image in PDF format 1 f View image in PDF format 1 View image in PDF format l View image in PDF format l View image in PDF format J 4 View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format 1 View image in PDF format 1 View image in PDF format J View image in PDF format 1 1 View image in PDF format [ View image in PDF format View image in PDF format J View image in PDF format 1 1 View image in PDF format 1 4 View image in PDF format J Note: This is not official record. See documents if question or conflict. Previous on List Events Next on List Name History Return To List Page 2 of 2 Entity Name Search Submit I Home I Contact us I Document Searches i E-Filing Services I Forms I Help l Copyright O and Privacy Policies State of Florida, Department of State http://www.sunbiz.org/scripts/cordet.ez e?action=DETFIL&inq_doc_number=N09556&incLcame... 7/26/2010 Credentials: Credentials for all physicians and medical personnel involved with the administration of the proposed services are in the following pages. These include: Senior Director Mercy Outpatient Services, Cardiology, Family Practice, Radiology, and Registered Nurses. We have provided current license verification from the State of Florida, Department of Health, showing no disciplines on file and no public complaints listed against physicians. Curriculum -Vitae of Contract Liaison Reuben J. Camp III, MSN, RN Family Practice Ines Braceras, M.D. Rheinchard Reyes, M.D. Cardiology Mahboobeh Goltapeh, M.D. internal Medicine Humberto Machado, M.D. Max Pazos, M.D. Radiologists South Florida Medical Imaging Staff Nurses Nancy Arocho, R.N. Milagros Losa, R.N. Reuben J. Camp III, MSN, RN 151 Michigan Avenue # 512 Miami Beach, FL 33139 (305) 285-1243 rcampmsnrn@aoI.com Administrative Nursing Summary of Qualifications E Knowledge and experience in hospital operations, strategic planning, program development and fiscal management of multiple departments. la Track record in establishing strong collaborative relationships between, Physicians, Nursing and Patient Relations E Productivity management EDUCATIONAL BACKGROUND Barry University Miami Shores, FL MSN Master of Science in Nursing Major: Nursing Administration Barry University Miami Shores, FL BSN Bachelor of Science in Nursing Community College of Rhode Island Warwick, Rhode Island ADN Associate Degree in Nursing ® Demonstrates cost management in accordance with hospital priorities and mission Accreditation and Program Certification E Presentation Skills E PC skills include (Database, Internet, and Microsoft Office, Exactcost ABC/ABM Management System, Kaufmann Hall Budget Software and Kronos/Visionware productivity module. 2001-2004 1994-1999 1972-1975 TEACHLNG AFFILIATIONS 6/2006-Present Barry University School of Nursing Miami Shores, Fl Assigned to instruct: • Nursing 679 Financial Strategies for Nurse Executives • Nursing 675 Human Resource Management for Nurses (Th PROFESSIONAL WORK EXPERIENCE 4/2010 Present Mercy Outpatient Center Mercy Research Institute Mercy Hyperbaric Chamber Mercy Neuroscience Center Senior Director, Mercy Hospital Miami, FL 33133 • Provides clinical leadership and administrative direction for the Mercy Outpatient Center (MOC), Mercy Hospital Inpatient and Outpatient Cardiac Diagnostics, Echocardiography, EKG, EEG , -Hyperbaric Oxyaeri Therapy"Center Neuro Science Program, Mercy Research Institute -,- International Travel Clinic, Center for Health Promotion, and the Freedom Preventive Care Programs (340b) at both Mercy Hospital Miami and Holy Cross Hospital Ft. Lauderdale. • Developed all "wellness and preventive care programs" for the Center for Health Promotion, including the International Travel Clininc, Executive Physical Exam Program, City of Miami Fire and Police Department, Hazmet Physicals and all special response teams. Provides Employment Physicals, Return to Work Exams, Drug Testing for the City of Miami and for multiple municipalities. • Established the Mercy Hospital and Holy Cross Hospital Freedom (340b) Preventive Care Programs from an outpatient perspective. Manages the administrative cost center and its financial resources —Controller and three (3) additional accounting resources. • Responsible for the entire Mercy Outpatient Center-Bayside Pavilion structure, cost center, and facilty maintenance. • Has complete responsibility for the revenue cycle for the MOC and Mercy Hospital departments including statistical reporting, PICC reporting, monthly budget exception reporting, vendor and service maintenance contracting, physician contracting, and the annual budgeting cycle including both threshold and non -threshold capital. • Troubleshoot staff/general administration conflicts and issues. • Resolves policy issues; develop reports and documents for budgeting proposals and expenditure control. • Responsible for the outpatient centers adherence to sound ethical business practice in accordance . with Corporate Integrity and Corporate Compliance. • Institutes patient, employee, environmental safety, infection control, and EOC management as a leadership priority, _ • Maintains compliance with specified safety and other practice standards. • Responsible for program specific/service line certification arid credentialing including Magnet and is an active member of the Magnet Steering Committee. • Maintains strong relationships with the Medical Staff so that medical directors have confidence in the daily management of the respective operating units. • Received no type one violations and no recommendations after a four -day JACHO survey in July 2009. • Responsible for the daily operation of the Mercy Hospital Research Institute, including budgeting and fiscal management. Develops Management Reports for senior management and other key decision makers. • Responsible for personnel management of the program, including hiring and termination, in consultation with Human Resources. • Set-up clear expectations for staff members and provide feedback to enhance staff performance. • Work with the Accounting staff to ensure timely and accurate monthly closings, including the preparation of the monthly financial statements. • Has established a positive and productive relationship_ with the physician principal investigators for the Mercy Research Institute. • Established productive relationships with department Medical Directors in order to improve the quality of service and to meet patient physician expectations. Mercy Outpatient Services Senior Director Mercy Hospital Miami, Florida 5/2006-4/2010 • Provides Clinical Leadership and administrative direction for all operations for the Mercy Outpatient Center-Bayside Pavilion; Womens Services, CAT Scaner, Ultrasound, Diagnostic Radiology, Nuclear Cardiology, Nuclear Medicine, In patient and Outpatient Cardiac Diagnostics, Echocardiology and EKG depai tanents at Mercy Hospital, as well as the Mercy Preventive Care Program (340b) at both Mercy Hospital and Holy Cross Hospital Hospital • Directs all "wellness and preventive care programs" for the Center for Health Promotion,. including the International Travel Clininc, Executive Physical Exam Program, City of Miami Fire and Police Depa, t,uent, Hazmet Physicals and all special response teams. Provides Employment physicals, Return to Work Exams, Drug Testing for the City of Miami as well as other municipalities. Estalished the Mercy Hospital and Holy Cross Hospital Freedom (340b) Preventive Care Programs from an outpatient perspective. • Manages the Administration cost center and its financial resources —Controller and three (3) aditional accounting resources. • Responsible for the entire Mercy Outpatient Center-Bayside Pavilion cost center and all building -maintenance. • Has complete responsibility for the revenue cycle for the MOC and its departments including statistical reporting, PICC reporting, monthly budget exception reporting, vendor and service maintenance contracting, physician contracting and the annual budgeting cycle including capital equipment • Oversees the MOC Registration and Scheduling departments and responsible for insurance verification and authorization. 0 • Troubleshoot staff/general administration conflicts and issues. • Resolve policy issues; develop reports and documents for budgeting proposals and expenditure control. • Responsible for the outpatient centers adherence to sound ethical business practice in accordance with Corporate Integrity and Corporate Compliance. • Institutes patient, employee, environmental safety, infection control, and EOC management as a leadership priority. • Maintains compliance with specified safety and other practice standards. • Responsible for program specific/service line certification and credentialing including Magnet and is an active member of the Magnet Steering Committee. • Maintains strong relationships with the Medical Staff so that Medical Directors have confidence in the daily management of the respective operating units. Provided administrative direction for the analogue to digital mammography conversion in 2008 for the MOC and published the experience in Radiology Management (2009). Center for Health Promotion and Cardiac Diagnostics Mercy Outpatient Center Director Mercy Hospital Miami, Florida 10/1999-5/2006 • Provides clinical leadership and administrative direction for the Mercy Outpatient Center's Center for Health Promotion and Mercy Hospital Inpatient and Outpatient Cardiac Diagnostics, Cardiac Rehabilitation, Echocardiography, EKG, Center for Health Promotion and the Freedom Preventive Care Program (340b) at Mercy Hospital. Developed all "wellness and preventive care programs" for the Center for Health Promotion, including the International Travel Clininc, Executive Physical Exam Program, City of Miami Fire and Police Department, Hazmet Physicals and all special response teams. Provides Employment Physicals, Return to Work Exams, Drug Testing for the City of Miami and for multiple municipalities. • Founded the Mercy Hospital International Travel Clinic • Provided the clinical leadership necessary to achieve Echocardiography Department Certification by (ICAEL) and Cardiac Rehabilitation (AACVPR). • Responsible for budget Center for Health Promotion and Cardiac Diagnostics Director Mercy Hospital Miami, Florida 1/2003-4/2006 • Responsibilities include the daily operations of inpatient and outpatient EKG, Holter Monitoring, Echocardiography and Trans Esophageal Echocardiography; the Center for Health Promotion provides medical services to the City of Miami Police and Fire Depatlments, and the International Travel Clinic —providing education and immunizations for persons traveling internationally. i Responsible for staffing and fiscal management of these departments, performance improvement activities and program certifications. The Director is also responsible for Capital Equipment Purchasing. I am a member of the Magnet Nursing Leadership Task Force as well as a member of the STEM1 Steering Committee. Has complete responsibility for the revenue cycle for the MOC and Mercy Hospital departments including statistical reporting, PICC reporting, monthly budget exception reporting, vendor and service maintenance contracting, physician contracting, and the annual budgeting cycle including, both threshold and non -threshold capital. Center for Health Promotion Director Mercy Hospital Miami, Florida 1993-2006 Founded the Center for Health Promotion. Responsible for the clinical leadership and administrative direction for the daily operation of the Center's programs including Cardiac Rehabilitation, EECP Therapy, International Travel CIinic, Executive Physical Exam Program, Wireless Capsule Endoscopy, Employee Health Services, and Osteoporosis Rehabilitation. Responsible for Cardiac Rehabilitation Program Certification through the American Association of Cardiac and Pulmonary Rehabilitation (AACVPR). Cardiac Rehabilitation Center Director Mercy Hospital Miami, Florida 1985-1993 Provided the clinical leadership and administrative direction for the Cardiac Rehabilitation Program Phases II, III and IV. Reviewer for Cardiac Rehabilitation Scope of Nursing Practice. PACE, Mercy Hospital Mercy Hospital Miami, Florida 1983-1985 Staff nurse relief charge nurse, assisted with the development of the PACU Open Heart Recovery Room Program. Emergency Department Mercy Hospital Miami, Florida Emergency Room staff nurse and relief charge nurse 3pm-11:OOpm. Cardiac Rehabilitation Mercy Hospital Miami, Florida 1980-1983 1979-1980 As director, provided the clinical leadership and administrative direction for the Cardiac Rehabilitation Program Phases II, 111 and IV. Surgical Intensive Care Mercy Hospital Miami, Florida Charge Nurse 3:00pm — 11: pm MEMBERSHIPS • ANA/FNA • American Orcanization of Nurse Executives • American Association of Occupational Health Nursing • American Association of Critical Care Nursing • Preventive Cardiovascular Nurses Association • Sigma Theta Tau International Honor Society Lambda Chi Chapter it 389185 • Kappa Gama Pi Catholic Honor Society • International Society of Travel Medicine (ISTM) 1976-1979 Professional Presentations and Publications Camp, R., & Monge, P (2009) Calculating the ROI for Analogue to Digital Mammography Conversion, Radiolo y Management, 31(3), 9-12. American Association of Cardiovascular and Puhnonary Rehabilitation (AACVPR) — Diversity in Exercise Programming: Project IDEA, 10`1' Annual Meeting, October13, 1995, Minneapolis, MN Professional Conferences Thirteenth Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. Health Management.: Building Partnerships for Success October 15-18, 1998 Denver, Colorado Twelfth Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. The Challenge of Change: From Guidelines to Delivery November 6-9, 1997 Dallas, Texas Twelfth Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. The Challenge of Change: From Guidelines to Deliveiy November 6, 1997 Dallas, Texas Eleventh Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. Promoting Health & preventing Disease September 19-22, 1996 Baltimore, Maryland Sixth Annual National Convention of the American Association of Cardiovascular and Pulmonary Rehabilitation. Looking ahead... Moving Forward November 6-9, 1991 Long Beach, California Educational Meetings and Seminars 11/04/2002 MentoringNurses Globally to -Promote Leadership Through Association Partnership - . Barry University. Professional Committee Memberships/Position 1992-1996 Member of American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Reimbursement Sub -Committee. 1992-1997 Reviewer for "The Scope of Cardiac Rehabilitation Nursing Practice" Document for the American Nurse Association's Council on Medical -Surgical Nursing Practice. STATE F. FLORIDA DEPARTMENTOE HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE •,... :,. ,, ..:, ••.,.- , ....f_5::Ati. „.. ., .. . ,:- ,...r „•,•.:•,. . ...,„: , ••••• •••...ppENSE NO.;,.:.., ' ,,.'!''' '•14ii-64tili6b. 04/44/2010 RN 879292::.. ..,.. i 206308 e sr,:teRg.1) : • med be ow has met all requirements of IOSiy$,00,:.,r,u10§xof#i0*!'sf.te of Flonda 33 SOUTH M!AMI AVENUE MI, FL 33133 • ;c Of-prli0:,1Orj,§t •Nt „ N:OR. • . • • STATE SURGEON GENERAL DISPLAY • • :..1'!:•:.i;:••• • lipun 1I munnumbation ur it 3fitrultB, IlpVuurb u'f rtnitrto flag ronfearb mi litmlutt Jatiat Tartly itt 111# btgree ut ilittott*t tiut itt t-trtii-tt. itt rennjuiliou of ill[g tiatiorartorli fnifitimput of rglittirtutguto prrittining tii tillo • 6ittpu 103 Bap ut 1JtIliq, alma elluutiaub Hub iffrnur itt Miami f,5711urtu, Buhr, Olnuntg, Vrrnib tut B Healthcare Practitioner License Printer Friendly Detail Information Display^ License Verification Data As Of 7/27/2010 INES BRACERAS LICENSE NUMBER: ME90901 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date 1/31/2012 Discipline on File NO... ... Address of Record 760 PONCE DE LEON BLVD. SUITE 107 CORAL GABLES, FL 33134 License Original Issue Date 07/02/2004 Public Complaint NO The information on this page is a secure, primary source for license verification provided by The Florida Department of Health, Division of Medical Quality Assurance. This website is maintained by Division staff and is updated immediately upon a change to our licensing and enforcement database. Page 1 of 1 https://ww2.doh.state.fl.us/IRM00PRAES/prasindi_print_report.asp?LicId=88289&ProfNBR=150... 7/27/2010 07-25-10;12,-,9PM: ;# 5/ 'Obadte7:0)1§t • --:'.;:-k: . , tAfirivt..viamontOi:Ro.'f,z RE:r.'..-,,:iiy,....pv . .. 114p-..49R =4:,.4.4,-,.. •.,. .' SWATE SURGEON ,ENLPAL '''......:.'. DISPLAY 14f601.172E66Tt4V :;2'.. .-;y,.,..p.1" nf 0 9IfeJ fttaria ilrtOeera 3, U1. having met all its requirements is hereby certified to be a i of this Board for the period 2004-2011 Executive Director addrSecretary President 07-26-10;12:c9FM; Ines M. Bracer -as. M.D.' ..-' Curriculum Vitae 1161 SW 13th Street Miami, FL 33129 Ph: 305-857-0303 Ce11: 305-807-0626 Email: bracerasmd@yahoo.com 2/ E Professional. Experience: Residency: Education: Ines M. Braccras, M.D. P.A. Family Practice Coral Gables, Florida Owner/Medical Director/Private Practice August 2006 - Present Mercy Hospital Miami, Florida Chairperson - Department of Family Medicine January 2008 - Present Mercy Hospital - Center for Health Promotion Miami, Florida Medical Director -October 2005 = Present -- Medical Professionals of Miami, Inc. Coral Gables, Florida Medical Director/Private Practice September 2004 - August 2006 Lehigh Valley Physician Group Allentown, PA Faculty Physician for the Family Practice Residency Program July 2004 - August 2004 Gables Rehabilitation Center Coral Gables, FL Administrator January 2001 - May 2001 Lehigh Valley Hospital Family Practice Residency, affiliated with Penn State University and Lehigh Valley Hospital Allentown, PA June 2001 - June 2004 Residency Director: Pamela F. LeDeaux, M.D. New York Medical College Valhala, New York January 2000 - December 2000 Fifth Pathway Program - Supervised CIinical Training. Universidad Autonoma De Guadalajara Jalisco, Mexico Medical Degree January 1996 - December 1999 University of Miami Coral Gables, FL Bachelor of Science in Biology with a minor in Chemistry and Psychology August 1990 - May 1994 Skills/Training: • Bilingual (English/Spanish) / Bicultural • Training experience included: Prenatal Care and Obstetrics, Behavioral Science, Geriatric Care, Pediatrics, Sports Medicine, Endocrinology, Nephrology, Alternative Medicine, Dermatology, Electronic Medical Records, Outpatient Care, and Evidence Based Medicine. • Cosmetic Laser Procedures for Primary Care - Empire Medical Training, Inc. • Aesthetics Procedures - The National Procedures Institute O7-26-10: 12:49PM: Achievements/ Affiliations: Licensure/ Certifications: • Fred Fister M.D. Family Medicine Award (The Graduating Resident Who Most Exemplifies The Values of Family Practice) - 2004 • Lehigh Valley Hospital Outstanding Resident Award - 2004 • Penn State University Exceptional Role Model Award - 2003 • Penn State University Exceptional Teacher Award - 2003 • Florida Department of Health - Certificate of Recognition for Outstanding Breast & Cervical Cancer Screening. - 2006 • Collegiate and Scholastic Football Team Physician 2002 - 2004 • Member - American Academy of Family Physicians • Member - American Medical Association • Member - Florida Medical Society • Board Certified in Family Practice • Florida. State Medical License • Certified Medical Review Officer • Advanced Cardiac Life Support Certification • Basic Life Support Certification 3/ 8 Healthcare Practitioner License Printer Friendly Detail Information Display License Verification Data As Of 7/27/2010 RHEIINCHARD ROBERTO REYES LICENSE NUMBER: ME77894 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date License Original Issue Date 1/31/2012 04/30/1999 Discipline on File Public Complaint NO NO Address of Record 3157 SW 21 STREET MIAMI, FL 33145 UNITED STATES The information on this page is a secure, primary source for license verification provided by The Florida Department of Health, Division of Medical Quality Assurance. This website is maintained by Division staff and is updated immediately upon a change to our licensing and enforcement database.' Page 1 of 1 https://ww2.doh.state.fl.us/IRMOOPRAES/prasindi_print_report. asp?LicId=73 964&ProfNBR=1 5 0, .. 7/27/2010 07-25-10; 12 49PM; 50 STATE OF FLORIDA DE l?fiRtii/LENT 0 F;:ii:LALTH D1V1SON OF MEDICAL QUALITYASSURANCE .'". i';''ir: i; I" . . *DATE,'•;.,.......:. . • !iv' -.";41,'''.7f, tf„."'"• ' ' ••'7i-1:::;.:::::', ef fi:";•,. r r..1.....grcENSE r\licXre,•,-'...;.r1 r,-,.....!.,-..---.,:.....r: -'1"i,,,,,,i, '..?", -:.., ...,,...,:,,,, ::.,,,,..i:-..r.:..i.0.0p41113.'QL5 :,..--,.;--, ,..:. - ....!,... ., • • • j90. • .• 11110/2009 ., . ... . - .... • . • ME 77894 - :, ' 294379 ..... ' • ' - ... . , • " •'-' The MEDICAL DOCTOR nameebe nit aIWfLrecnents of:: 1 state of Forida. Eiration Date JANUARY:31, ENCHRDFtOSERTO REYEs .• • • 64.: • ., •• .-.. . . ., ..,, .. k.'...: .... ..... -;s: 1. - '''' ,.:',.• -. ....,.......::, r: . V t:h a ilk Grist AP). GOVERNOR • DIS'OLAYIRR '6UIRED13.SYT:' LAATVVE 717. 0 LU w • . , - .' - .- EXPIRATION DATE: . JANUARY. 31, 2012 Your,license number is IME 77894: -please' usc it in' all carresoondenee with:your board/council. Each licensee is solely 'responsible for notifying the departrnent in writing ol t :ensee!d current mailing address and practice:location address. If you have notrceeivcd your renewal notiee.9.0 days prior. to the expiration date shown on this license, . .. . . . . •• . , • • . . . • • _ .. . . • . . ..- ,.„.. ... , . . - Use this.neetion to -report name change;Ptarne changes require legal dochinenration showing the name change. Please mako. sure that a photocopy of one of the following . _ . accompanies this form:Ii.marriage licenam'ef.divorce 'decree, aka court A driver's license.M,MiMial Security card is•net considered Lela] dochraentatIon.- . . • • . . . • , ... • • . • , , . . . . . Medical QualityAisurance offers you the convenience of siveral.online seMices.'Thise:seryiees give •you the ability -to renew. your license, update your mailing and practice • • , • • •..• lecation.addrenses and. update your - Profile information.- • . • • ' .., .- -. -..• - •• - - •• .. en CO tu -- 1, Go to ormirSihealthsource.com • 2 Click on Licensee/Provider' - . ••• • . • ' . _ ' • -5: Cnter.the accourd.ID and'password that was provided to you on your initial license and click on ,.q„arsin,,,. .- . .-.: ..-.-• : :..- ,.: ,. . . , . . .-, . . .. . . ::..... ' .r.6:iry,ou.do pot know your account ID and passworcl,"cliek on Get Login gtelp.t•or call'aur Ptistomer Contact Center at.(850)£3-9505 for assistance. .• • • • .. • •.,•. •. • • .. . .. • ..."•.• . . . .• ' • . „ • -7. • • . . . . . • • . . • . MAIL TO: DEPARTMENT OF HEALTH ' ' . '•. • .• DIVISION OF NIEDICAL QUALITY ASSURANCE • , • LICENSING AND AUDITING SERVICES UNIT: ---::- • • ; P.O. BOX 6320 TALLAHASSEE, FLORIDA-32314:.:620'. • NAME CHANGE (ATTACH LEGAL DOCUMENTATION) • • :•• , • • l• • ' . '• .MIDDLE LAST. FIRST•i.MIDGLE 07-26-10;12,49PM; 1 7/ E Founded 1969 James C. PuJ%r, M.D. President and Chief Executive Officer Michael D. Hagen, M.D. Senior' Vice President -Roger M. Bean, CPA Chief Operating Officer Terrence M. Leigh, Ed.D. Vice President Examination Administration and Credentials Joseph W. Tollison, MD. Senior Advisor to the President Marlin A. Quan, M.D, Senior Advisor to the. President Robert F. Avant. M.D. Executive Director Emeritus Paul P. Young. M.D. Executive Director Emeritus 22251'ovu� Drive Laiufiiun. KY 41159E-47.94 Trl: I KMNI 995-5 71111 X59) 269-5t26 Fax: 059) 335-7501 059) 33E-7599 swm.16•,•nl,rut.org ri:� ,ltarrirna )k a,'!:rt :1•ir',iica! ,VLK'q!alti, American September 30, 2008 To Whom It May Concem: of Family Medicine, Enc. This letter verifies Rheinchard Roberto Reyes, MD is currently certified with the American Board of Family Medicine (ABFM). Family Medicine Certification History: Jul 26, 2008 - Dec 31, 2015 Jul 14, 2000 - Dec 31 2007 Certification in Family Medicine is for a period of seven years. A Certificate of Added Qualifications (Geriatrics, Sports Medicine, etc.) has a length of 10 years. From 1970 through 2002, certification was renewed by completion of requirements for Recertification. Bach physician (Diplomats) fulfilled the obligation of maintaining a full and unrestricted medical license, earning 300 hours of continuing medical education (Civ1E), and successfully completing the recertification examination. Beginning in 2004 with the family physicians who passed Certification and Recertification examinations in 2003, the ABFM began a gradual transition from Recertification to Maintenance of Certification for Family Physicians (MC -FP). MC -FP is designed to transition all Diplomates into the program by 2010, enrolling all physicians who certify or recertify as they successfully pass the examination. The MC -FP program is divided into separate three-year stages. By completing Stage l and Stage 2 by specified deadlines, the life of a certificate will be extended from seven to ten years. Diplomates who are unable to complete these requirements will retain their original seven-year certificate. Regardless of whether a Diolomate is on a 10 year or 7-year cycle, MC -FP requirements must be completed prior to applying for the next cognitive examination. The prior requirements for licensure and CME are incorporated into the requirements of the MC -FP. Details of the MC -FP process are available online at www.theabfm.org. Sincerely, Kathy Baker Verification Coordinator 07-26-10:i2:49PIW: # 6/ �I IIIMMOICIOS Rheinchard Reyes, MD 760 Ponce De Leon BLVD Suite 107 Coral Gables, FL 33134 305.445.3372 305.445.3359 fax Education University of Miami, Coral Gables, Florida Graduated: May 1992 Degree: Bachelor's of Science Howard University College of Medicine, Washington, DC Graduated: June 1996 Degree: Medical Doctor McAllen Family Practice Residency Program, McAllen, Texas Completed: June 1999 Degree: Family Practice Specialty Work Experience Rheinchard Reyes, MD, PA Solo Practice since February 2004 Sterling Physician Services June 2001— April 2004 Emergency Room Physician Coral Gables Hospital Westchester General Hospital Certifications BLS, PALS, ACLS instructor 09/2008-09/2010 Professional Associations American Academy of Family Practice Updated 01/2004 Healthcare Practitioner License Printer Friendly Detail Information Display._ Page 1 of 1 License Verification Data As Of 7/27/2010 HUMBERTO MACHADO LICENSE NUMBER: ME16190 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date License Original Issue Date 1/31/2011 12/31/1973 Discipline on File Public Complaint _ NO _ _ NO _ Address of Record 747 PONCE DE LEON BLVD. #403 CORAL GABLES, FL 33134 UNITED STATES The information on this page is a secure, primary source for license verification provided by The Florida Department of Health, Division of Medical Quality Assurance. This website is maintained by Division staff and is updated .=Tmedlately upon a change to our licensing and enforcement database. ) • https://ww2.doh.state.fl.us/IRM00PRAES/prasindi_print_report.asp?LicId=11511 &ProfNBR=150... 7/27/2010 n AC .215 6 9 5 STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTROL NO. 11126/2008 ME 16190 263636 The MEDICAL DOCTOR named below has met ali requirements of the laws and rules of the stale of Florida. Expiration Date: JANUARY 31, 2011 HUMBERTO MACHADO 747 PONCE DE LEON BLVD. #403 CORAL GABLES, FL 33134 UNITED STATES eaer.z-k. Charlie Crist . Ana M. Viamonte Ros, M.D., M.P.H. GOVERNOR STATE SURGEON GENERAL DISPLAY IF REQUIRED BY LAW I r tb Ito rev f A D rt.-L.-LPL( nv, rFJ D rf kej_._ Fame DEA-223 (05104) DEAREW8TRAT10N uUMBER CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C.20537 THIS REGISTRATION EXPIRES FEE PAID AM0213Tbb 01-31-2011 Paid SCHEDULES BUSINESS ACTNRY DATE ISSUED 2,2N,3 PRACTITIONER 3N14,5 01-e7-2000 MACHADO, HUMBERTO MD 1A7 PONCE DE LEON BLVD SUITE 403 CORAL GABLES, FL 33134 Sections 301 and 1008 (21 U.S.C. 1124 and 458) of the Controlled Subsialces AOl of 1970. as amended, provide Thal the Attorney General may revoke or suspend a registration to n anuhdu,e . distribute, dispense, import or expos a controlled.substence. THIS CERTIFICATE IS NOT TRANSFERABLE•ON CHANGE OF OWNERSHIP, CONTROL, LOCATION. BUSINESS ACTIVITY, OR VALID AFTER THE EXPIRATION DATE. - 0 0 CURRICULUM VITAE HUMBERTO MACHADO. M.D.. F.A.C.C.. P.A. Diplomate, American Board of Internal Medicine, Sub -specialty of Cardiovascular Disease. Practice limited to Cardiovascular Disease. 747 Ponce de Leon Suite 403 Coral Gables, Florida 33134 Date of Birth: April 15, 1939, Havana, Cuba Degrees: Bachelor of Science. Institute del Vedado, Havana, Cuba. Licentiate in Medicine and Surgery. University of Salamanca, - - School of Medicine,Spain 1965 Internship: 06/24/66- 06/23/67 University of Miami, School of Medicine and Jackson Memorial Hospital, Miami, Florida. Straight Medicine Internship. Residency: 06/24/67- 02/28/69 02/26/71- 06/30/71 University of Miami, School of Medicine and Jackson Memorial Hospital, Miami, Florida. Resident in Medicine (after completion of Military Service, vide infra). Fellowship: 07/01/71-06/30/73 University of Miami, School of Medicine and Veterans Administration Hospital, Miarni, Florida. Senior Fellow in Cardiology. 07/01/71-06/30/72 University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida. Fellow in Cardiology. Military Service: 02/70-02/71 Chief of Medical Section at the Armed Forces Entrance and Examination Station, Coral Gables, Florida (Honorable Discharge) 10/69-02/70 Major, U.S. Army Medical Corps. Assigned to the 3rd Field Hospital, Saigon, Republic of Vietnam. Chief of Internal Medicine Clinic. 04/69-10/69 Captain, U.S. Army Medical Corps. Assigned to the 9th Infantry Division, Republic of Vietnam. MEDALS AND CITATIONS: Bronze Star Medal Army Commendation Medal National Defense Service Medal Vietnam Service Medal Vietnam Campaign Medal Presidential Unit Citation Meritorious Unit Citation Curriculum Vitae Page 2 ACADEMIC APPOINTMENTS: 1973- present • Associate Clinical Professor Of Medicine (Cardiology), University of Miami, School of Medicine. 07/01/73- present Consultant to the Cardiovascular Laboratory and attending in Cardiology. University of Miami, School of Medicine, Jackson Memorial Hospital and Veterans Administration Hospital. 02/82-08/82 Consultant and Co -Director Non-invasive Cardiology Mount Sinai Medical Center, Miami Beach, Florida. 09/00- present Director, Dept. of Echocardiography, Mercy Hospital, Miami, Florida. - Founding President of -American -Society of Echocardiography, South Florida Chapter and - Greater Miami Society of Echocardiography. Medical Education for Florida, Mayo Clinic Satellite Tele-Conference 1980 — present 1981- present 1999 - present MEDICAL SOCIEUi S: 2002 1979 1973- present 1976 1981 1971-present 1975 1974-1980 Co -Director, Annual Symposium, Greater Miami Society of Echocardiography. Co- Director , Annual Symposium, Presented by Miami Cardiac & Vascular Institute. Advisor, Mercy Hospital, Heart Failure Program Fellow of the American Society of Echocardiography Fellow of the American College of Cardiology Member of the American College of Physicians Fellow of the American College of Physician Fellow of the American Heart Association Fellow of the Council on Clinical Cardiology Member of the Dade County Medical Association Fellow of the American Society of Internal Medicine Fellow of the American College of Angiology Founding President, Greater Miami Society of Echocardiography CERIllICATONS AND STATE LICENSES: 1966 Educational Council for Foreign Medical Graduates (ECFMG), (by examination) 1970 Licensed by Florida State Board of Medicine Examiners (by examination) 1975 Diplomate of the American Board of Internal Medicine 1979 Diplomate of the Sub -specialty of Cardiovascular Disease 2002 Certified by National Board of Echocardiography 2008 Machado Cardio, Inc. Certificate of Accreditation from The Intersocietal Commission for the Accreditation of Echocardiography Laboratories Curriculum Vitae Page 3 SCIENTIFIC PUBLICATIONS: 1) Humberto Machado, M.D.,; Azucena G. Arcebal, M.D.; Cesar A. Castillo, M.D.; Agustin Castellanos, Jr, M.D.and Louis Lemberg, M.D.: His Bundle Recording in Patients with Acute Myocardial Infarction. Clinical Research. Vo1.XX, No. 1, January 1972. - Humberto Machado, M.D.; -Louis Lemberg, M.D.; His Bundle Recordings in Patients with Acute inferior Wail Myocardial Infarction. Clinical Research. Vol. XX, No. 1, pg. 23, January 1973. 3) Humberto Machado, M.D.; Azucena G. Arcebal, M.D.; Louis Lemberg, M.D.; Cesar A. Castillo, M.D. and Agustin Castellanos, Jr., M.D.: His Bundle Electrograms in Type If (Mobitz) Block Occurring During Acute Myocardial Infarction. American Heart Association 45d' Scientific Session, Dallas, Texas. Abstract #4997, Supplement II, Vols. XLV and XLVI, October 1972. 4) Humberto Machado, M.D.; Rapidly Progressive Aortic Insufficiency in Reiters Syndrome. Annals of Internal Medicine. Vol. 81, July 1974. 5) 7) 8) r) Humberto Machado, MD. ; B. Befeler , M.D.; David E. Wells , M.D.; Richard J. Theurer, M.D.; Agustin Castellanos, Jr. M.D.: Intra- Coronary Steal Syndrome Resulting from Aortocoronary Bypass Surgery. American Heart Journal. Vol. 89, No. 5,pp 633-637, May 1975 Humberto Machado, M.D.; B. Befeler, M.D.; J.M. Aranda, M.D.; D.E. Wells M.D.; N. ElSheirf, M.D. and r. Lazzara, M.D.:Coronary Artery Aneurysms in a. Population with Ischemic Heart Disease, (Abstract) Circulation. Vol. 52, No. 4, October 1975 Humberto Machado, M.D.; David E. Wells, M.D.; Benjamin Befeler, M.D.; Ralph Lazarra, M.D.; and Abraham Embi, B.S.: Mitral Valve Prolapse and Coronary Artery Disease. Clinical Hemodynamic and Angiographic correlations. Circulation. Vol. 52. PP 245-253, August 1975. Humberto Machado, M.D.; David E. Wells, M.D.; Agustin Castellanos, M.d.: Veterans Administration Hospital, University of Miami, School of Medicine, Miami, Florida: Spatial Displacement of the QRST Vectors in the Evaluation of Aorto-Coronary Bypass Flow. (Abstract) American College of Cardiology, 22dd Annual Scientific Session. San Francisco. February 1973. Curriculum Vitae Page 4 9) 10) 11) 12) 13) 14) Huumberto Machado, M.D.; David E. Wells, M.D.; Agustin Castellanos, M.D.: Veterans Administration Hospital, University of Miami, School of Medicine, Miami, Florida: Dilating Coronary Atherselerosis (Abstract). Sociedad Venezolana de Cardiologia, X Interamerican Congress of Cardiology, 1976 Humberto Machado, MD.; B. Befeler, MD.: Miami, Florida. Hemodynamic Characteristic of Obstructive Cardiomyopathy with Emphasis on Right _ Ventricular Outflow Obstruction. Angiology. Vol. 30, No.1, p 27, January 1979. Humberto Machado, MD.: Stephen D. Clements, Jr., MD,: Brian Remington, MD.: John V. Perkins, MD and Judy Gantier-Perez: University of Miami School of Medicine, Miami, Florida and Emory University School of Medicine, Atlanta, Georgia: Chordal Systolic Anterior Motion in Mitral Valve Prolapse; A M- Mode Two Dimensional Study (Abstract). 53rd Scientific Session of the American Heart Association. Humberto Machado ,MD,; Evlin L. Kinney, MD.: Bernard Schrager, MD.; Roert A. Chahine, MD.; The Detection of Thrombosed Aortic Bjork- Shiley Valve by Two Dimensional Echocardiography. American Heart Journal. Humberto Machado, MD.; Evlin L. Kinney, MD.; Xavier Cortado; David L. Galbut, MD.; Diagnosis of Discrete Subaortic Stenosis by Pulsed and Continuous Wave Echocardiography. American Heart Journal. Vol 110, No. 5, PP 1069-1071, November 1985. Humberto Machado, MD,; Evlin L Kinney, MD,; Cooling intracardiac Sound in. a Perforated Porcine Mitral Valve Detected by Pulsed Doppler Echocardiography. American Heart Journal. Vol. 112, No. 2, PP 420-423. August 1986. 15) Humberto Machado,; B Befeler, MD,; Life Threatening Ventricular Arrhythmia's Terminating Spontaneously in a Patient with Mitral And Tricuspid Valve Prolapse. A Possible Cause of Sudden Death. (Manuscript- June 1989). Curriculum Vitae Page 5 16) 17) Humberto Machado, MD,; 0 Santana, MD.; S. Safirstein, MD.; D. Williams, MD.; A. Agaston, MD.: Non- invasive Documentation Of the interventricular Septum Due to Subacute Bacterial Endocarditis. (Video of Echocardiography-vol. 2, No 1, pp 26-28, January 1992). Humberto Machado, MD,; Oscar R. Guerra MD,; Steven Safirstein. MD and Arthur S. Agaston, MD.; Protruding Atheromas in the Aortic Arch In - Patients with Cerebrovascular Syndromes. (Video Journal of Echocardiography -Vol. 2, pp59-64, April 1992): 18) Humberto Machado, MD.; Current Application of Tranesophageal Echocardiography. (Mercy Medicine- Vol 3, No 3, 1992). 19) Humberto Machado, MD., FACC,; Alberto Interian, MD., FACC,; Heart Failure Sudden Cardiac Death; Going Beyond Drugs. March 8, 2003 20) 21) Humberto Machado, MD, FACC, FASE; Alberto Interian, M.D., FACC; Cardiac Resynchronization Therapy 2005 Heart Failure Drugs and Davies. September 10, 2005 Humberto Machado, M.D., FACC, FASE; Alberto Interian M.D., FACC; Heart Failure and its Relationship to Sudden Cardiac Death. August 23, 2006. Hospital Affiliations (Continued): Mount Sinai Medical Center 4300 Alton Road Miami Beach, Florida 33140 Jackson Memorial Hospital 1611 NW 12th Avenue Miami, Florida 33136 Palmetto General Hospital 2001 West 68th Street Hialeah, Florida 33016 Hialeah Hos ital 651 East 25 Street Hialeah, Florida 33013 Page 1 of 1 Protecting Human Subject Research Participants Certificate of Completion The National Institutes of Health (NIH) Office of Extramural Research certifies that Humberto Machado successfully completed the NIH Web - based training course "Protecting Human Research Participants". Date of completion: 07/06/2010 Certification Number: 473850 http://phrp.nihtraining.com/users/cert.php.?c=472850 7/15/2010 Healthcare Practitioner License Printer Friendly Detail Information DisplayPare 1 of 1 1 r v License Verification Data As Of 7/26/2010 MAHBOOBEH GOLTAPEH LICENSE NUMBER: ME50341 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date 1/31/2012 Discipline on File License Original Issue Date 04/27/1987 Public Complaint NO — NO . Address of Record 3661 5 MIAMI AVE #904 MIAMI, FL 33133 The information on this page is a secure, primary source for license verification provided by The Florida Department of Health, Division of Medical Quality Assurance. This website is maintained by Division staff and is updated immediately upon a change to our licensing and enforcement database. https://ww2.doh.state.fl.us/i1u100Praes/prasindi_print report.asp?LicId=41904&ProfNBR=1501 &... 7/26/2010 ( ahis is to &IA 94- 3lwlalibin (504aPth 1:5as-13e tntlecteb FELLOW August 3ot 1996 113543 OARD Cjp NIT INCORPORATED 1936 ATTESTS. THAT 6tritaptii HAS MET THE REQUIREMENTS OF THIS BOARD At IS HEREBY DESIGNATED A DIPLOMATE CERTIFIED IN THE SPECIALTY OF INTERNAL MEDICIT E SEPTEMBER 13, 1989 e...4 10D-T-•• 1' te' >4.61-e6e9b ted e0242/11t dede iUaIbnnhrij 6411141 1,ezd ‘-e,e ceeei eo-dz,tedd erAlbe/ite eed eZe l'ezefrt,61/1-ec 1L de Wk:, oi/gleZzie0ha, aialea7 de pa, /SS dae tVt etc;g,7-bez.&;(e 4-6 IUi • e/r.4I eia3 (a Healthcare Practitioner License Printer Friendly Detail Information Display ) License Verification Data As Of 7/26/2010 MAX PAZOS LICENSE NUMBER: ME41056 ' Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date License Original Issue Date 1/31/2012 10/27/1982 Discipline on File Public Complaint NO Address of Record 5040 NW 7 STREET SUITE 700 MIAMI, FL 33126 UNITED STATES NO The information on this page is a secure, primary source for license verification provided by The Florida Department of Health, Division of Medical Quality Assurance. This website is maintained by Division staff and is updated immediately upon a change to our licensing and enforcement database. Page 1 of 1 https://ww2.doh.state.fl.us/IRM00PRAES/prasindi_print_report. asp?LicId=33002&ProfNBR=15 0... 7/26/2010 .t___a i.— i _—J t .. -'E D dFINTER\A INCORPORATED 1936 ATTESTS THAT Max litt50o HAS MET THE REQUIREMENTS OF THIS HEREBY DESIGNATED A.DIPLOMATE THE SUBSPECIALTY OF CARDIOVASCULAR DISE CHAIRMAN AMERICAN BOARD OF INTERNAL MEDICINE 41, V- ga,J121, NumBER 113810 C AN -ELECT AMERICAN B OF INTERNAL MEDICINE SUBSPECIALTY BOARD ON CARDIOVASCULAR DISEASE DATE OARD AND IS ERTIFIED IN DeitzadT. SECRETARY -TREASURER AMERICAN BOARD OF INTERNAL MEDICINE OVEMBER 8, 1989 FORM 7C • INCORPORATED 1936 4 VA, ATTESTS THAT L HAS.MET THE REQUIREMENTS OF THIS BOARD AD IS HEREBY 441457 M. AV ISECAETAT-17.E.SW.Eff ITIE5rDEKT LI % DESIGNATED A DIPLOMATE CERTIFIE]1 THE SPECIALTY OF IN INTERNAL MEDICINE ge-1 2,461 141 GP 54-.11- 31krk 6.1414_t_ Details 71 Atieti afderge___ attiAtt- Attp4-, -A- 113810 DA/ IR SEPTEMBER 16, 1981 1 FCRV4 3067•117 ficA\ AYI .1 A INCORPORATED 1936 Al iESTS THAT alt a5i110 WHO LS A DIPLOMATE IN INTERNAL MEDIGIINE HAS MET THE REQUIREMENTS OF THIS BO AND IS HEREBY CER Ian TO HAVE SPECIAL QUALIFICATIONS IN CRITICAL CIE'MEDICINE FOR THE PERIOD L991 THROUGH .2001 E - ‘CHAOMAS Ascencm Boorg5br prIIERNALMETICPM Vh. 'amen 113810 !airstismturnEcT A.Mair:AK WARD or INTIM& MIXICINE TEST COMMITTEE ON CRITICAL CARE MEDICI] 6. 14,x1c; NO ER 5, 1991 : • • Curriculum Vitae Max Pazos, M. D, P.A.. 747 Ponce De Leon, Suite 305 Coral Gables, Florida 33134 (305) 665-3129 Education Pos Universidad Central del Este Dominican Republic Doctor of Medicine University of Miami Miami, Florida Bachelor of Science in Chemistry and Science Magna Cum Laude Miami Dade Community College Miami, Florida Associate in Arts Graduate Trainine Brown University Providenoe, Rhode island Cardiology Fellowship Massachusetts GeneraUSt. Vincent's Hospital Worcester Massachusetts Cardiology Fellowship Brown University Program!Memorial Hospital Providence, Rhode Island Internal Medicine Training Yale University/St. Mary's Hospital Waterbury -New Haven, CT. General Surgery Training 1980 _u��Kits�•�--�2 :s�:•tF.z�sn��x� ��r?ss-w,.eater'u.�t�v»e^ra�+��sr._„�,.�->.�na 1977 1975 1987-1988 1986-1987 1981-1983 1981-1963 173 Areas of Expertise • Cardiac Catheterization Halter Monitor reading, Swan -Ganz insertion and management. Incubation, Chest Tube insertion and management. Echodoppier, Exercise Stress testing, Nuclear Imaging, interpretation and report. Management of critical care medical / surgical patients. Languages English and Spanish Awards "SeniorResident of the Year Award" 1986 Brown University Providence, Rhode Island Special Certifications American Board of Internal Medicine 1987 American Board of Cardiovascular Diseases' 1989 American Board of Gritical care Medicine 1991 ractice Solo Practice 1988-Present " ;,.::,,,,'1::?•:,.):.:,:iA::'...r74:-.1,T:::-.;:• ,--,. < - , _..''. 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LICENSE The • -namee.fjeloiietia the J#Szv..§440e . ofilOtate of FlQnda i',T;tANOARr31,2011 JOEL rifiidi4ELiiLktniir 4725 NORTfk'FpER*,-HIqtfwAY:.. DEPT. OiR01,04:4 •FORtOOLORP4g;, • ONTR9L NO 276110 '44 o. 0 •, 0. uJ co • ( Jan 29 09 0922p James D. Davenpod, M.D. 3056530198 STATE'dF iFLdRIDA • ••: • DEPARTMENT OR HEALTH , • pIWISION QF MEDICAL QUALITY ASSURANCE . I - •-• • DATE,- ! 01 i;(4/2069 ,!•• .* ,LI.GENSE :rr.: :;CONTROL.NO. - • Fhe MEDICAL DOCTOR lamed befowha. Mit' all requirements of he laws:•icd: rules of fhe of Florida. „JANUARY 31, 2011 %11i1I8H;AAGAIMAL 29 EAST COMMERCIAL T LAUDERDALE; FL: 332108 3NITED STATES., *•,:•, Q.nadie;ript GOVERNOR • , • - 1 • ME 96844 274.519 101 ....••:kW' 10. Viarnarlte;.R9 STATE SURGEON GENERA.U!, !'s DI& LAY IFREQUIRED:.BYLAW k ( -(3 0 z w r • tlj ui •tc• EXPIRATION DATE: JANLIAR-Y 21. aoii P.1 oq•-•,-r• < en , .E; — - - - - . .0.EF'ARTME14715F. HEALTH STATE Or FLOEIGA:l. AC# 3.2::8-'8.0 DMSION OF':;PIEDlCAL QUALITY ASSURANCE , • LICENSE NO. ME 103850 CQNTROL NO. • - 28 mEDHCA ...1,:pOLIOR • n'antedte)ow fig indaifrequirenients of 04;10yra.aarfAulaaall/e state or Florida. dfu..••A::-.-JANUARY 31, 20/1 LICENSEE SIGNATURE STA.TE OF FLORIDA DEPARTMENT OF HEALTH •-• c\.4. DIVISION OF MEDICAL QUALITY ASSURANCE *. 1:ATE. ';: :.. :-. . .-„, :'.--: LICENSE NO. . . ;-: t'i CONT .RO:LiNO. 03107/20 9 RN 2562922 1072347 a,beowhasrit all, retirements Of teslavys and rules pf:tha.state of Florida. )?iratiOnpate:.'; iApFtiL 30,:,2011 ANCY LEE -"AROCI1ol, 331 CORAL BOULEVARD IIRAMARF( 33023 5980- - 0. 0 0 0 z < < Z F12.1 - :3 t; • < " • < X"C.D Z 0 W F- < C73 5 CD 0 a Charlie Crist .[..,,, ,<',-,:. 7. -,,, ,,----•,,.. :Ana M. Viamonte Ros,M-.1D,,, Mi.P.H,,,,----•-,:,:,, :-:b.C.WERNIOR • STATE SUR0E0NO.ENER4, :1.1. f!:.--t'..... ','• .,:...-...;...-,.-- DISOJAY--1RiCt:),..tREC.:.',01.:LAW "-,-...• .,,,;::• :-..-:-.::...,S,1-' :i'.,:_...E:* ‘!•-....„:;:i.'..;',,..'''' _ . . 0 ori o • 0 07/27/2010 TUE 10:52 FAX 3052855015 aumen Rebourceb Healthcare Practitioner Lici ) Display License Verification Data As Of 7/17/2010 MILAGROS LOSA LICENSE NUMBER: RS2752582 Zool/ool Page 1 of 1 Punter Friendly Version a °snerd Information Profession REGISTERED NURSE LIcenee/ActJVIty Status CI FAR/ATV. Li1ente expiration Date 4/30/2012 Discipline on File License Original Issue Dale 07/07/1993 Public Complaint 14 NO NO Address of Record MERCY HOSPITAL 3663 SOUTH MIAMI AVENUE MIAMI, FL 33123 The Information on this page Is a secure, primary source for license verification provided by The Florida Department Of Health, Divi; ion of Medlol Quality Assurance. This websitc Is maintained by Division staff and is updated Immediately upon 6 Change to our ilcensing and enforcement database. http://ww2.doh.state.fl.us/itm00praes/PRASINDI.ASP?Lield=13 8765&ProfNBR=1 7 01 7/27/2010 ' __) Hospital JOINT NOTICE OF PRIVACY PRACTICES THIS JOINT 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 EFFECTIVE DATE: APRIL 14, 2003 (Revised 7/04) If you have any questions about this Joint Notice, please contact the Hospital's Privacy Officer at (305) 854-4400, ext. 3711 or (305) 860-4675. WHO WILL FOLLOW THIS JOINT NOTICE • -The Joint Notice -describes -the- Hospital's practices -and -those -of-- — 1. Marshall, Amaya & Anton, M.D., P.A., the Emergency Room physicians, providing services as independent contractors to the Hospital. 2. Marjorie B. Sanders, M.D., d/b/a Mercy Diagnostic Radiology Associates, the Radiologists, providing services as independent contractors to the Hospital. 3. Mercy Anesthesia Group, L.C., the Anesthesiologists and Certified Registered Nurse Anesthetists, providing services as independent contractors to the Hospital. 4. Davjen Pathology Consultants, P.A., the Pathologists, providing services as independent contractors to the Hospital. 5. Critical Care Consultants, P.A., the lntensivists, providing services solely in said capacity and not as physicians engaged in private practice, as independent contractors to the Hospital. n 6. Carlos Lavernia, M.D. Orthopedist, providing orthopedic services as an independent contractor to the Orthopedic Institute of the Hospital. 7. All departments and units of the Hospital. 8. Any member of a volunteer group we allow to help you while you are in the Hospital. 9. All employees, staff, students, faculty, and other Hospital personnel. 10. Mercy Outpatient Center 11. Mercy Laboratory Associates 12. Mercy Home Health Agency 13. St John Bosco Clinic 14. Mercy Outpatient Pharmacy 15. All these persons, entities, sites and locations follow the terms of this Joint Notice. In addition, these persons, entities, sites and locations may share information with each other for treatment, payment, or hospital operations purposes as described in this Joint Notice. OUR PLEDGE REGARDING MEDICAL INFORMATION We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This Joint Notice applies to all of the records of your care generated by the Hospital, and by the Emergency Room physicians, Radiologists, Anesthesiologists, Pathologists, Intensivists and Orthopedist members of the Orthopedic Institute, whether made by Hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This Joint Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. r'� We are required by law to: make sure that medical information that identifies you is kept private; give you this Joint Notice ,_.) of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the Joint Notice that is currently in effect. Form 967-011 (Rev. 7/04) - 1 - HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU --, The following categories describe different ways that we use and disclose medical information. For each category of uses )or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories. For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or other hospital personnel who are involved in taking care of you at the Hospital. For example, a doctor treating you for a broken hip may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. We also may disclose medical information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital, such as family members, clergy, or others we use to provide services that are part of your care, such as therapists or physicians. For Payment. We may use and .disclose medical information about you, so that the treatment and services you receive at the Hospital may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received at the Hospital so ---your-health-plan-will pay- us- or- reimburse-yourfor-the-treatment. We -may -also -tell. -your health_ pIan about -a treatment. - you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Healthcare Operations. We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the Hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Hospital patients to decide what additional services the Hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and healthcare delivery without learning the identities of specific patients. Appointment Reminders. Treatment Alternatives. and Health Related Benefits and Services. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Hospital. We also may use and disclose medical information to tell you about or recommend possible treatment options, alternatives, health -related benefits or services that may be of interest to you. Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the Hospital and its operations. We may disclose medical information to a foundation related to the Hospital so that the foundation may contact you in raising money for the Hospital. We only would release contact information, such as your name, address and phone number, and the dates you received treatment or services at the Hospital. If you do not want the Hospital to contact you for fundraising efforts, you must notify the Hospital's Privacy Officer in writing. Hospital Patient Directory. We may include certain limited information about you in the Hospital directory while you are a patient at the Hospital. This information may include your name, location in the Hospital, your general condition (e.g., fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy of your declared religion, such as a priest or rabbi, even if they don't ask for you by name. This is so your family, friends, and clergy can visit you in the Hospital and generally know how you are doing. If you do not want anyone to know this information about you, you must notify the Hospital's Privacy Officer in writing or indicate your preference on the Hospital's Patient Authorization Form. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. This would include persons designated by you as a health care surrogate, named in any durable health care power of attorney or similar documents provided to us. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information Form 967-011 (Rev. 7/04) - 2 - about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. Research. Under certain circumstances, we may use and disclose medical information about you 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. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the Hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the Hospital. SPECIAL SITUATIONS As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement 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 medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits. Workers' Compensation. We may release medical information about you for Workers' Compensation or similar programs. These programs provide benefits for work -related injuries or illness. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: to prevent or control disease, injury, or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare 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 medical information about you in response to a valid court or administrative order. We .may also disclose medical information about you 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 medical information if asked to do so by a law enforcement official: in response to a valid court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material 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 at the Hospital; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime. Form 967-011 (Rev. 7/04) - 3 - (�1 Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner, This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about deceased patients of the Hospital to funeral directors as necessary to carry out their duties upon the request of the patient's family. National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be 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; (3) for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes and other mental health records under certain circumstances. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Hospital's Director of Health Information Management. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy medical information in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the Hospital will review your request and the denial. The person conducting the review will be the person 'who denied your request. We will comply with the outcome of the review. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Hospital. To request an amendment, your request must be made in writing and submitted to the Hospital's Director of Health Information Management. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by or for the Hospital; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list of accounting of disclosures, you must submit your request in writing to the Hospital's Director of Health Information Management. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example: on paper, electronically). 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. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit Form 967-011 (Rev. 7/04) - 4 - on the medical 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 do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Hospital's Director of Health information Management. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to Confidential Communications. You have the right to request to receive communications from us on a confidential basis by using alternative means for receipt of information or by receiving the information at alternative locations. We must accommodate your request, if it is reasonable. You are not required to provide us with an explanation as to the basis of your request. Contact the Director of Health Information Management if you require such confidential communications. Right to a Paper Copy of This Joint Notice. You have the right to a paper copy of this Joint Notice. You may ask us to give you a copy of this Joint Notice at any time. Even if you have agreed to receive this Joint Notice electronically, you are still entitled to a paper copy of this Joint Notice. To obtain a paper copy of this Joint Notice, request a copy from the Hospital's Privacy Officer in writing. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this Joint Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you. CHANGES TO THIS JOINT NOTICE We reserve the right to change this Joint Notice. We reserve the right to make the revised or changed Joint Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Joint Notice in the Hospital. The Joint Notice will contain on the first page, in the lower left-hand corner, the effective date. In addition, each time -you register at or are admitted to the Hospital for treatment or healthcare services as an inpatient or outpatient, we will offer you a copy of the current Joint Notice in effect. COMPLAINTS & QUESTIONS If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the Department of Health and Human Services. If you have any questions about this notice or wish to file a complaint with the Hospital, contact the Privacy Officer at (305) 854-4400, ext. 3711 or (305) 860-4675. All complaints must be submitted in writing. You will not be penalized for filing a complaint. HOW TO EXERCISE YOUR RIGHTS To exercise your rights described in this notice (other than to obtain a copy of this notice), you must contact the following individuals: Request to Access, Amend, Confidential Communications, Restrict, and Account For Disclosures: Records Custodian, Health Information Management Department, Mercy Hospital, 3663 South Miami Avenue, Miami, FL 3313.3 Privacy Complaint: Privacy Officer, Corporate Compliance Department, Mercy Hospital, 3663 South Miami Avenue, Miami, FL 33133 Form 967-011 (Rev. 7/04) -5- Outpatient Center AUTHORIZATION TO RELEASE AND COMMUNICATE PROTECTED HEALTH INFORMATION (PHI) TO FAMILY MEMBERS AND FRIENDS ACCT# MR# DOB FC Patient Acknowledgment I have been given a copy of Mercy Hospital's Joint this form, I consent to the Hospital's use and disclosure and health care operations, as well as for those purposes to revoke this authorization, in writing, except where already made disclosures in reliance on my prior If acknowledgment of receipt of the Joint Notice of representative, please explain your efforts to obtain ❑ Patient refused to sign Reason: of Receipt of Joint Notice of Privacy Practices Notice of Privacy Practices, version effective April 14, 2003. By signing of protected health information about myself for treatment, payment set forth in the Joint Notice of Privacy Practices. I have the right Mercy Hospital or the other entities identified in the Joint Notice has consent. For Hospital Use Only Patient's Initials Privacy Practices is not obtained from the patient or the patients their acknowledgment and the reason you -could not obtain it: . ❑ Unable to obtain signature • Other Mercy Hospital Representative Signature Date Facility Directory Instructions This form authorizes or restricts the release of your name and location in Mercy Hospital's Facility Directory. Information about you generally wit be included in our Facility Directory to enable family and concerned individuals to inquire about your location and condition on the nursing unit only. We will disclose your location and your general condition only to individuals who ask for you by name. Additionally, we will disclose any religious affiliation that you provide us to members of the clergy based on information received during the admission process. However, you may restrict the information included in the Directory and to whom the disclosure is made by indicating your preferences below. ❑ I want to be included in the Hospital Facility directory. I understand my name, location, and general condition will be made available to friends, family, and outside callers and religious affiliation will be made available to my choice of clergy and/or Pastoral Care. Patient's tnitiats If you do not want to participate in the Facility Directory, please indicate below what you wish to be excluded: 0 Your name and location. i understand that if I do not consent to this disclosure, visitors who I have not given my name. room number, and/or telephone number will not be able to contact me. O General condition. O Religious affiliation. Note: Visitors include family and friends, outside phone cafferS; and"florists. I understand that if I do not consent to this disclosure, answers to ouesions regardino my general condition wit not be given to family and friends. I understand that if I do not consent to this disclosure, my religious affiliation will not be made available to clergy and Pastoral Care. Patient's Initials Form 967-010MOC Rev. 01/07 Authorization for verbal Communication to Family Members and Friends In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rules, I authorize my health care information to be disclosed for purposes of communicating results, findings, and care ;cisions to my family members and others responsible for my care or designated by me. I understand that _.,formation in psychotherapy notes or sensitive patient information (substance abuse records and/or HIV test results) wilt not be disclosed without my specific authorization. I authorize the two following individuals to receive verbal communications regarding issues related to my health care. Mercy Hospital will not communicate with anyone other than the two individuals you indicate below. When choosing individuals, note the following: * one person must be your health care surrogate, if you have designated a health care surrogate * one person should be located locally, if at all possible * you must provide an identifier for each person * you must initial and date names of persons that are added or deleted after the initial request ❑ I do not wish to designate any individual Please print the following information: DOB, Tel # or Initial Add -on Name of Person Other Identifier or Deletion Date To replace a person's name, if deleted above: Name of Person DOB, Tel # or Initial Add -on Date Other tdPntifier or Deletion *---Date of Admission / Treatment: ' —;his authorization will expire upon discharge. Authorization for Case Management continuity of care is extended post discharge for issues related to this admission. Authorization to Communicate Sensitive Patient Information * Psychotherapy/psychiatric consultation or notes: I authorize and hereby consent that the verbal communications may contain information regarding psychotherapy/psychiatric consultation or notes. • Yes • No (initials) * Substance abuse records: I authorize and hereby consent that the verbal communications may contain substance abuse records. * ❑ Yes El No (initials) HIV test results: I authorize and hereby consent that the verbal communications may contain HIV test results. ■ Yes ❑ No (initials) PATIENT SIGNATURE Date: / / Patient name (print) Print name if health care surrogate or proxy Patient Signature/Health Care Surrogate / Proxy Relationship to patient Witness signature Print name if witness ('- ithorization to Release and Communicate Protected jalth Information (PHI) to Family Members and Friends Hospital 1111 11111 II 11 II II II 11 11 Form # 967-010 Page.2 of 2 Current: 06/30/09 ACCT# MR# DOB FC Patient Acknowledgment of Receipt of Joint Notice of Privacy Practices -'-have been given a copy of Mercy Hospital's Joint Notice of Privacy Practices, version effective April 14, 2003. signing this form, I consent to the hospital's use and disclosure of protected health information about myself for treatment, payment and health care operations, as well as for those purposes set forth in the Joint Notice of Privacy Practices. I have the right to revoke this authorization, in writing, except where Mercy Hospital or the other entities identified in the Joint Notice have already made disclosures in reliance on my prior consent. For Hospital Use Only Patient's initials If acknowledgment of receipt of the Joint Notice of Privacy Practices is not obtained from the patient or the patient's representative, please explain your efforts to obtain their acknowledgment and the reason you could not ❑ Patient refused to sign Reason: ❑ Unable to obtain signature El Other Mercy Hospital Representative Signature Date Facility Directory Instructions This form authorizes or restricts the release of your name and location in Mercy Hospital's Facility Directory. (--formation about you generally will be included in our Facility Directory to enable family and concemed _,:;dividuals to inquire about your location and condition on the nursing unit only. We will disclose your Location and your general condition only to individuals who ask for you by name. Additionally, we will disclose any religious affiliation that you provide us to members of the clergy based on information received during the admission process. However, you may restrict the information included in the directory and to whom the disclosure is made by indicating your preferences below. ❑ I want to be included in the Hospital Facility Directory. I understand my name, location, and general condition will be made available to friends, family, and outside callers, and religious affiliation will be made available to my choice of clergy and/or pastoral care. Patient's initials Jf you do not want to participate in the Facility Directory, please indicate below what you wish to be excluded: ❑ Your name and location I understand that if I do not consent to this disclosure, visitors who I have not given my name, room number, and/or telephone number will not be able to contact me. Note: Visitors include family and friends, outside phone callers, and florists. ❑ General condition I understand that if I do not consent to this disclosure answers to questions regarding my general condition will not be given to family and friends. ❑ Religious affiliation I understand that if I do not consent to this disclosure, my religious affiliation will not be made available to clergy and Pastoral Care. Patient's initials f-^-ithorization to Release and Communicate Protected t Jalth Information (PHI) to Family Members and Friends MERar Hosp Sal Form # 967-010 Page 1 of 2 111 II 11 II 11 11 11 II Current: 06/30/09 ACCT# MR# DOB FC M., Outpatient Center AUTORiZACION PARA DIVULGAR Y COMUNICAR INFORMACION PROTEGIDA DE SALUD (PHI) CON MIEMBROS DE LA FAMILIA Y AM ISTADES ACCT# MR# DOB FC Reconocimiento del Paciente del Reclbo de La Notificacion de Privacidad del Mercy Hospital He recibido una copia de la Notificacion de Privacidad del Mercy Hospital, version vigente desde el 14 de abril del 2003. Al firmer este documento, autorizo al Hospital a utilizer y a divulgar informacion confidential medica sobre mi persona con fines de tratamiento, pagos o servicios medicos, asi como para los propositos que se han estipulado en esta Notificacion de Privacidad. Tengo el derecho a revocar esta autorizacion por escrito, excepto donde el Mercy Hospital o las otras entidades nombradas en esta Notificacion de Privacidad hayan divulgado informacion utilizando mi consentimiento previa. _ . Para Uso_Del Hospital Solamente Iniciales del Paciente If acknowledgment of receipt of the Joint Notice of Privacy Practicos is not obtained from the patient or the patient's •representative, picase explain your efforts to obtain their acknowledgment and the reason you could not obtain it: • ❑ Patient refused to sign ❑ Unable to obtain signature ❑ Other Reason: Mercy Hospital Representative Signature Date Instrucciones Para El Directorio Del Hospital Este formulario autoriza o restringe la divulgacion de su nombre o localizacion en el Directorio del Mercy Hospital. Incluimos su informacion general en nuestro directorio para que su familia y las personas interesadas en su salud puedan preguntar acerca de su localizacion y su condicion en la estacion de enfermeria solamente. Le indicaremos su localizacion y su condicion general a las personas preocupadas por su salud que puedan identificarlo por su nombre. Ademas, le revelaremos a miembros del clero la afiliacion religiose que usted ha indicado durante, la evaluation initial que se efectue en la unidad despues de su admision. Sin embargo, usted puede restringir la informacion que se incluye en el directorio, y a quien se le divulge la misma, al indicar a continuation su preferencia. ❑ Deseo que me incluyan en el Directorio del Hospital. Entiendo que mi nombre, localizacion y condicion general estaran disponibles para mis amistades, parientes y personas que Ilamen al hospital. Iniciales del Paciente Si no desea ser incluido en el Directorio del Hospital, por favor indique a continuation que usted desea ser excluido: ❑ Nombre y localizacion, Entiendo que al negarme a proveer esta informacion, los visitantes no se podran poner en contacto conmiao a menos aue vo mismo les have dado mi nombre, ni mero de habitation y/o telefono. Nota: Los visitantes incluyen miembros de la familia, Ilamadas fuera del hospital y entregas de floristerias. O Condition general. Entiendo que al negarme a divulgar esta informacion, mis amistades y mi familia no podran obtener respuestas acerca de mi condicion general. ❑ Afiliacion religiose Entiendo que al negarme a divulgar esta informacion, mi afiliacion religiose no ester a disponible para miembros del clero o pare el sacerdote del hospital. Iniciales del Paciente Autorizacion Para La Comunicacion Verbal Con Miembros De La Familia y Amistades De acuerdo con las reglas de privacidad de La Ley de Responsabilidad y Portabilidad del Segura Medico de 1996 (HIPAA), autorizo que mi informacion de salud se divulgue con el proposito de comunicar resultados, hallazgos, y decisiones sabre mi salud a mi familia a a otras personas responsables por mi cuidado o designados por mi. Entiendo que informacion acerca de notes psicoterapeuticas o informacion que puede ser sensitive pars el paciente (registros de abuso de sustancias y/o resultados de la prueba del virus VIH) no seran divulgados sin mi previa autorizacion. Form 967-0D9MOC Rev. 01/D7 Autorizo a los siguientes dos individuos a que reciban informacion respecto a los asuntos relacionados con el cuidado de me salud. El Mercy Hospital no se comunicara con nadie que no este designedo e indicado a rrntinuacion. Al escoger los individuos favor de tomar en consideration. Una persona debe ser su representante sobre el cuidado de su salud, se tiene un representante sobre e cuidado de su salud. • Una persona debe residir localmente, si es posible. • Usted debe proveer una clave para identificar a cada persona. • Debe poner sus iniciales y las fecha al lado de los nombres del las personas que se anadan o se eliminen despues de las solicitud initial. ❑ No deseo designar a ninguna persona. Favor escribir en tetra de molde la siguiente informacion: Fecha de nacimiento, Iniciales para edad, numero de telefono anadir o eliminar Nombre de la persona u otro identificante personas Fecha Para reemplazar el nombre de una persona indicada anteriormente: Fecha de nacimiento, Iniciales para edad, numero de telefono anadir o eliminar Nombre de is persona u otro identificante personas Fecha • Fecha de admision/tratamiento: • Esta Autorizacion expirara cuando el paciente sea dado de alta. La Autorizacion para la continuidad del cuidado -m. bajo el Departamento de Servicios Sociales se extiende despues que el paciente es dado de alta para asuntos relacionados•con este admision. Autorizacion pars comunicar informacion sensitive del paciente • Consultas o notas psicoterapeuticas/psiquiatricas: Autorizo y doy mi consentimiento para que las comunicaciones verbales incluyan informacion acerca de consultas o notas psicoterapeuticas o psiquiatricas. 0 Si 0 No (firme sus iniciales) • Archivos de abuso de sustancias: Autorizo y doy mi consentimiento para que las comunicaciones verbales incluyan registros acerca del abuso de sustancias. ❑ Si ❑ No (firme sus iniciales) • Resultados del examen del virus VIH: Autorizo y doy mi consentimiento para que las comunicaciones verbales incluyan resultados de la prueba del virus VIH. 0 Si ❑ No (firme sus iniciales) FIRMA DEL PACIENTE Nombre del paciente (en letra de molde) Firma del paciente/Representante del paciente sobre el cuidado de su salud Firma del testigo Fecha Escriba en Tetra de molde el nombre del representante del paciente sobre el cuidado de su salud Parentezco con el paciente Nombre del testigo (en letra de molde) torizacion Para Divulger y Comunicar Information Protegida ue Salud (PHI) Con Miembros De La Familia y Amistades Hospital III II II III 11 II Form # 967-0105 Page 2 of 2 Current: 06/30/D9 ACCT# MR# DOB FC Reconocimiento del Paciente uel Recibo de La Notification de Privacidad del Mercy Hospital He recibido una copia del la Notification de Privacidad del Mercy Hospital, version vigente desde el 14 de abril del 2003. Al firmer este documento, autorizo al Hospital a utilizer y a divulgar information confidential mediae sobre mi persona con fines de tratamiento, pagos o servicios medicos, ast como para los propositos que se han ' tipulado en esta Notification de Privacidad. Tengo el derecho a revocar esta autorizacion por escrito, excepto ..ende el Mercy Hospital o las otras entidades nombradas en esta Notification de Privacidad hayan divulgado information utilizando mi consentimiento previo. Para Uso Del Hospital Solamente Iniciales del paciente If acknowledgment of receipt of the Joint Notice of Privacy Practicos is not obtained from the patient or the patient's representative, please explain your efforts to obtain their acknowledgment and the reason you could not obtain it: ❑ Patient refused to sign ❑ Unable to obtain signature ❑ Other Reason: • . Mercy Hospital Representative Signature Date Instrucciones Para El Directorio Del Hospital _ Este formutario autoriza o restringe la divulgacion de su nombre o localizacion en el Directorio del Mercy Hospital. Incluimos su information general en nuestro directorio para que su familia y las personas interesadas en su salud puedan preguntar acerca de su localizacion y su condicion en la estacion de enfermeria solamente. Le indicaremos su localizacion y su condicion general a las personas preocupadas por su salud que puedan identificarlo por su nombre. Ademas, le revelaremos a miembros del clero la afiliacion religiose que usted he indicado durante, la evaluation inicial que se efectuo en la unidad despues de su admision. Sin embargo, usted puede restringir le information que se incluye en el directorio, y a quien se le divulge la misma, al indicar a continuacion su preferencia. . ❑ Deseo que me incluyan en el Directorio del Hospital. Entiendo que mi nombre, localizacion y condicion general ----, estaran disponibles para mis amistades, parientes y personas que Ilamen al hospital. �, Iniciales del paciente Si no desea ser incluido en el Directoria del Hospital, por favor indique a continuacion que usted desea ser excluido: 0 Nombre y localizacion Entiendo que al negarme a proveer este informacion, los visitantes no se oodran - poner en contacto conmioo a rnenos que vo mismo les hava dado mi nombre, numero de habitation y/o telefono. Note: Los visitantes incluyen miembros de la familia, Ilamadas fuera del hospital y entregas de floristerias. ❑ Condition general Entiendo que al negarme a divulgar este informacion, mis amistades y mi familia no podren obtener respuestas acerca de mi condicion general. 0 Afiliacion religiose Entiendo que al negarme a divulgar este informacion, mi afiliacion religiosa no estara disponible pare miembros del clero o para el sacerdote del hospital Iniciales del paciente Autorizacion Para La Comunicacion Verbal Con Miembros De La Familia y Amistades De acuerdo con las reglas de privacidad de La Ley de Responsabilidad y Portabilidad del Seguro Medico de 1996 (HIPAA), autorizo que me informacion de salud se divulgue con el proposito de comunicar resultados, hallazgos, y decisiones sobre mi salud a mi familia o a otras personas resporisables por mi cuidado o designados por mi. Entiendo que informacion acerca de notas psicoterapeuticas o informacion que pueda ser sensitive para el paciente (registros de abuso de sustancias y/o resultados del la prueba del virus VIH) no seran divulgados sin mi previa autorizacion. c utorizacion Para Divulger y Comunicar Information `'-Yrotegida De Salud (PHI) Con Miembros De La Familia y Amistades -.. Hospital II 11 III II II III Form # 967-010S Page 1 of 2 Current: 06/30/09 ACCT# MR# DOB FC Client List City of Miami Ana Cobelo Administrative Assistant II City of Miami Employee Relations Department 444 South West 2nd Avenue Seventh Floor Miami, Florida 33130 Tel: 305.416.2101 acobeici miamigov.com Reveca Valiente-Ortiz, Personnel Services Coordinator City of Miami Employee Relations Department 444 South West 2 Avenue Seventh Floor Miami, Florida 33130 Tel: 305.416.2113 Fax: 305.416.2115 Rvaliente-ortiztmiamieov.com EHE International Office of the President Adam Berman 10 Rockefeller Plaza, 4th Floor New York, NY 10020 Tel: 212.332.3700 Mike Pokrywka Network Development Representative EHE International Office: 212.332.3025 Fax: 212.332.1169 mookrvwkaseheintl.com Archdiocese of Miami 9401 Biscayne Boulevard Miami Shores, Fiorida 33138 305.893.0068 List of Clients that have Discontinued Services: Not applicable to Center for Health Promotion. We have not lost any clients in the past three years. Proposer's Facility: All services proposed will be performed at the Mercy Outpatient Center, Bayside Pavilion, 3641 South Miami Avenue, Miami, Florida 33133. The Bayside Pavilion is a 90,000 square foot, four story building. Physical Exams (Annual, Employment, Options) The Center for Health Promotion, located in the Mercy Outpatient Center at Bayside Pavilion, is a 2,500 square foot facility offering an upbeat setting in which wellness physical exams, cardiovascular stress testing, and immunizations are performed. The facility has a large waiting area designed to comfortably accommodate patients. The physical exam area consists of five private exam rooms, interview areas, as well as small conference rooms for counseling sessions. The adjacent parking garage has ample space and will accommodate prospective or current city employees free of charge. In addition, there is room for City of Miami Fire Rescue to park directly outside the facility close to the Center for Health Promotion. The emergency plan at Mercy Outpatient Center provides guidelines for the staff to react to untoward incidents and to perform their duties in a way that will minimize the consequences of an incident. This emergency plan addresses more than procedures; it also addresses staff skills, supplies and equipment, support personnel, practice, and risk management. Complete preparations have been made for the handling of potential cardiac emergency. The facility is equipped with a fully stocked crash cart, oxygen supply, and a portable defibrillator. All staff nurses are Advanced Cardiac Life Support Certified (ACLS). The facility is equipped with a general emergency alarm system, and an emergency hotline to the Hospital. Emergency transport routes have been well mapped. It is now policy that staff members activate the Emergency Medical System (EMS) by calling "911", and procure an expected time of arrival (E.T.A.). Mock emergencies are conducted annually and are integral components of the Center's continuous quality improvement plan (C.Q.I.). Mercy Hospital and Mercy Outpatient Center's employees have completed HIPPA training and are familiar with notice of privacy practices established and placed in effect on April 14, 2003. The Center for Health Promotion is equipped with all of the equipment to perform the necessary testing requested in the RFP. The Center is equipped with (3) EKG machines, (2) Pulmonary Function Spirometers, (5) Welch -Allyn Audioscopes for hearing evaluation / screening, and (4) Quinton 4500 Stress Testing Units. In the Nuclear Medicine Department there are (4) Nuclear Imaging Cameras (Thallium) and back-up echocardiogram and 24 Holter Monitor Units. The Radiology Department is equipped with (5) x-ray rooms, (2) mammography roorns and units, and has the ability to perform immediate breast biopsies. Hepatitis A and B and Miscellaneous Immunizations immunizations are performed at the Center for Health Promotion. Reports of those City employees that are completed, due, and overdue for immunizations, are forwarded to the responsible party monthly. Directions and Parking Mercy Outpatient Center is located in the Bayside Pavilion at 3641 South Miami Avenue, just seconds away from the Vizcaya Museum and Gardens. If you have an appointment, you should park in the Visitor's Parking Garage 1. You will see the garage on your left hand side, as you enter the hospital grounds. Parking is free of charge for City of Miami clients. Mercy Hospital is easily accessible from 1-95. If you're traveling south on 1-95, take the S.W. 25th Road exit toward the Key Biscayne/Rickenbacker Causeway. You will then make a slight left on to S.W. 26th Road and an immediate right onto South Miami Avenue. Follow the signs to Mercy Hospital, which is located on the left. If you are traveling North, take US 1 towards Downtown Miami, turn right at SW 17th Avenue. Proceed to South Bayshore Drive and make a left. You should then make a right on Mercy Way. If you are traveling from the West Miami area, take 836 East to 1-95 South connecting to US 1. Go straight on US 1 to 17th Avenue and make a left. Proceed to South Bayshore Drive and make a left. You should then make a right on Mercy Way. Line: 1 Description: Employment and Promotional Physical Examinations for Non Sworn Classifications Line: 1.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Unit Price: $ 66 Line: 1.2 Number of Units: 425 Total: $ Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line; 1.3 1.3 Number of Units: 600 Total: Description: Additional/Optional Examination Components: Back X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ 75 Line: 1.4 Number of Units: 5 Total: $ Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 50 Total: $ / Page 4 of 41 Line: 1.5 Description: Additional/Optional Examination Components: EKG (12 lead) Category: 94874-50 Unit of Measure: Each Unit Price: $ /35 Line: 1.6 Number of Units: 425 Total: $ 572 376- Description: Additional/OptionalExamination Components: -Rubella Titer - Category: 94874-50 Unit of Measure: Each Unit Price: $ a - Line: 1.7 Number of Units: 5 Total: $ 00 Description: Additional/Optional Examination Components: Rubella Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 5 Total: $ /4 Line: 1.8 Description: Additional/Optional Examination Components: Review of Miscellaneous Medical Records Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 5 Total: $ 4:9 Page 5 of 41 Line: 1.9 Description: Additional/Optional Examination Components: Hepatitis A, B, and C Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.10 Number of Units: 25 Total: $ /i /e;?-5-- Description: Additional/Optional Examination Components: HIV Testing & Counseling - ELISA Test Category: 94874-50 Unit of Measure: Each Unit Price: $ .33 Line:1.11 00 Number of Units: 25 Total: $ Description: Additional/Optional Examination Components: HIV Testing & Counseling - Western Blot Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.12 Number of Units: 25 Total: $ /i /cs Description: Additional/Optional Examination Components: HIV Testing & Counseling - Pre Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 25 Total: $ 7 5 o G Page 6 of 41 Line: 1.13 Description: Additional/Optional Examination Components: HIV Testing & CounseIing - Post Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ ,JS Line: 1.14 00 Number of Units: 25 Total: $ S Description: Additional/Optional Examination Components: HIV Testing & CounseIing - Measles, Mumps, Rubella Immunization —S Category: 94874-50 Unit of Measure: Each Unit Price: $ /55 Line: 1.15 Number of Units: 5 Total: $ 66-- Description: AdditionaUOptional Examination Components: HIV Testing & Counseling - Tetanus Vaccine 35 r,LO Category: 94874-50 Unit of Measure: Each Unit Price: $ 6— Line: 2 Number of Units: 5 Total: $ T6" Description: Employment Physical Examinations for Firefighters (Examination shall be conducted pursuant to current NFPA 1582 Guidelines and City of Miami Medical Protocols) Line: 2.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Page 7 of 41 Unit Price: $ Line: 2.2 Number of Units: 60 Total: $ // Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Unit of Measure: Each Unit Price: $ 7:55— Line: 2.3 Number of Units: 60 Total: $ Description: Additional/Optional Examination Components: EKG Category: 94874-50 Unit of Measure: Each (Th ) Unit Price: S Number of Units: 60 Total: $ 0 Line: 2.4 Description: Additional/Optional Examination Components: Back X-Ray • Category: 94874-50 Unit of Measure: Each Unit Price: $ / 75" Line: 2.5 - Number of Units: 1 Total: $ 7 5 " Description: Additional/Optional Examination Components: Cardiovascular Stress Test Category: 94874-50 Unit ofMeasure: Each Unit Price: $ 471 41 5' Number of Units: 60 Total: $ Page 8 of 41 Line: 2.6 Description: Additional/Optional Examination Components: HIV Testing & Counseling - ELISA Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 55 Line: 2.7 Number of Units: 60 Total: $ 01) Description: Additional/Optional Examination Components: HIV Testing & Counseling - Western Blot Category: 94874-50 Unit of Measure: Each Unit Price: $ sz-c Line: 2.8 Number of Units: 60 Total: $ c2, 7-0 0 Description: Additional/Optional Examination Components: HIV Testing & Counseling -Pre Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.9 Number of Units: 60 Total: $ / I a-z) Description: Additional/Optional Examination Components: HIV Testing & Counseling - Post Counseling Category: 94874-50 Unit of Measure: Each Unit Price: $ ,357 Number of Units: 60 Total: $ 02/ Page 9 of 41 Line: 2.10 Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ / -Line: -2..11 Number of Units: 60 Total: $ /i D 8 d Description: Additional/Optional Examination Components: Hepatitis A,13 and C Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ `L S Line: 3 Number of Units: 60 Total: $ / -oo Description: Employment Physical Examinations for Police Officers (Examination shall be conducted pursuant to current California Peace Officer Standards and City of Miami Protocol) Line: 3.1 Description: Basic Physical Examination (including lab work, visual exam, and audiological exam) Category: 94874-50 Unit of Measure: Each Unit Price: $ - Line: 3.2 Number of Units: 60 Total: $ .2 /f ba 0 Description: Additional/Optional Examination Components: Chest X-Ray Category: 94874-50 Page 10 of 41 Unit of Measure: Each Unit Price: $ /3 Line: 3.3 Number of Units: 60 Total: $ 7/ / 0-6 Description: Additional/Optional Examination Components: EKG Category: 94874-50 Unit of Measure: Each Unit Price: $ /3 Number of Units: 60 Totat: $ i Line: 3.4 Description: Additional/Optional Examination Components: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 47/ Line: 3.5 Number of Units: 60 Total: $ o2Si 5 CA° Description: Additional/Optional Examination Components: Back X-Ray Category: 94574-50 Unit of Measure: Each Unit Price: $ / 7S Line: 3.6 Number of Units: 1 Total: $ / 7 Jr c2 Description: Additional/Optional Examination Components: Hepatitis A, B, and C Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 60 Total: $ a / 7-D O Page 11 of 41 Line: 3.7 Description: Additional/Optional Examination Components: PPD Test Category: 94874-50 Unit of Measure: Each Unit Price: $ / -3:8 1 Number of Units: 60 Total: $ 6 4 g o Description: Additional/Optional Examination Components: Pulmonary Function Category: 94874-50 Unit of Measure: Each Unit Price: $ 75- Number of Units: 1 Total: $ Line: 3.9 Description; Additional/Optional Examination Components: Blood Type & Rh Typing Category: 94874-50 Unit of Measure: Each Unit Price: $ /6-- Line: 3.10 Number of Units: 1 Total: $ Description: Additional/Optional Examination Components: Rubella Titer Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 1 Total: $ Page 12 of 41 Line: 3.11 Description: Additional/Optional Examination Components: Rubella Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 3.12 Number of Units: 1 Total: $ Description: Additional/Optional Examination Components: Review & Provide Written Interpretation of Medical Records Category: 94874-50 Unit of Measure: Each Unit Price: $ 02� Line: 4 Number of Units: 1 Total: $ oL` Description: Return to Work Physical Examinations for all Classifications Line: 4.1 Description: Return to Work Physical Examinations Category: 94874-50 Unit of Measure: Each Unit Price: $ 16— Number of Units: 400 Total: $ 5 i erT'`c) Page 13 of 41 Trade Secrets Execution to Public Records Disclosures: There are no Trade Secrets contained in this proposal.