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Exhibit 6
admit Cntr RFP Number: 243229,1 Title: Annual Physical Examination Services For First Responders 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, Suite 246 Miami, FL 33133 Office: 305-285-2624 Fax: 305 — 860k-4614 scamp@mercymiami.org TABLE OF CONTENTS Section 1 Cover Sheet Section 2 Table of Contents Section 3 Executive Summary ■ Executive Summary signed and dated. ■ Certification Statement • Certification ■ Fee Proposal Section 4 Section 5 Professional Experience ■ 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 ■ 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 Out patient 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 technology with 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 Miami, Florida 33133-4205 i / irj�.a,d Date Contact Person at Mercy Outpatient Center Reuben J. Camp III, MSN, RN Senior Director, Mercy Hospital Outpatient Services Tel: 305.285.2624 Fax: ,5.860.4614 Reuben J. Camp III I N, 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 120 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, E.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 (1) certify that any and all information contained in this submission is true; and we (1) 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 (1) agree to abide by all terms and conditions of this solicitation and certify that 1 am authorized to sign this submission for the suhmitter. Please print the following and sign your name: / crt ,y74 SUPPLIER NAME: / 626,rPA I7 r ADDRESS: 3tc4/ 17 £ aaa.-C I PHONE. 25 o� k5 - ,26� c� FAX:- - �6,e) - 4/6 EMAILti�G - e m `e-e-' `/4lie BEEPER SIGNED BY: TITLE: V 30-51;i'ecs U � / aPme.1 E. l//7 //c) FAILURE TO COMPLETE, SIGN. AND RETURN THIS FORM SHALL DISOUALIFY THIS BID. Page 2 of 54 Certifications Legal Name of Finn: /14-- .4/(e.lcifirre--.-271- lie,,,2a4,/ Entity Type: Partnership, Sole Proprietorship, Corporation, etc. Year Established: Office Location: City of Miami, Miami -Dade County, or Other Occupational License / Business Tax Receipt Number: k5 — o4SO Occupational License / Business Tax Re ct Issuing Agency: 2lI %-Lor-,cfa_ /J r Occupational License / Business Tax Receipt Expiration Date: _ /J Respondent certifies that (s) he has read and understood the provisions of City of Miami Ordinance No. 10032 (Section l -105 of the City Code) pertaining to the implementation of a "First Source Hiring Agreement.": es or No) Do you expect to create new pos ions in your company in the event your company was awarded a Contract by the City? (Yes o o)) In the event your answer to question above is yes, how many new positions would you create to perform this work? V 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. Please list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e. Addendum No. 1, 7/1/07). If no addendum/addenda was/were issued, please insert N/A. Page 3 of 54 Page 4 of 54 Line: 1 Description: GROUP 1 - FIRE -RESCUE ANNUAL PHYSICAL EXAMINATION SERVICES, INCLUDING HEPATITIS A and B PROGRAM. Line: 1.1 Description: Basic Physical Category: 94874-50 Unit of Measure: Each Unit Price: $ /� •• SC) Line: 1.2 va NurnberofUnits: 400 Total: $ �" �`c-() Description: Additional/Optional Exams: Speculum and Bi-Manual Exam including Pap Smear Category: 94874-50 Unit of Measure: Each Unit Price: $ 3 Y. 5-6 Line: 1.3 Number of Units: 50 Description: Additional/Optional Exams: Mammogram Category: 94874-50 Unit of Measure: Each Unit Price: $ / 75 Line: 1.4 00 Total: oc> Number of Units: 50 Total: $ $ , 75° — Description: Additional/Optional Exams: Comprehensive Hearing Test Category: 94874-50 Unit of Measure: Each Unit Price: $ �J Number of Units: 20 Total: $ 7` -70 vv Page 5 of 54 Line: 1.5 Description: Additional/Optional Exams: Echocardiogram Category: 94874-50 Unit of Measure: Each Unit Price: $ 3'9-5— Line: 1.6 o-e3 Number of Units: 200 Total: $ %�/> 'CO Description: Additional/Optional Exams: Thallium Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ j 3Z Line: 1.7 Number of Units: 50 Total: $ Description: Additional/Optional Exams: Exercise Muga Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 6 Line: 1.8 Number of Units: 10 Total: $ (al 0C Description: Additional/Optional Exams: Hepatitis A and B Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ 3�- Number of Units: 200 Total: $ OC} Page 6 of 54 Line: 1.9 Description: Additional/Optional Exams: Tetanus Toxoid Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ emu" Line: 1.10 Number of Units: 50 . Description: Additional/Optional Exams: Tetanus Booster Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.11 Number of Units: 75 Total: $ 474:` Total: $ off-/ 7O--e Description: Additional/Optional Exa Category: 94874-50 Unit of Measure: Each Unit Price: $ r)Q Line: 1.12 s: Pulmonary Function Test - Flow Volume Loop Number of Units: 50 Total: $ i r Description: Additional/Optional Exams: Pulmonary Function Test - Post Bronchodilatory Study Category: 94874-50 Unit of Measure: Each Unit Price: $ 77? Line: 1.13 Number of Units: 50 Total: $ 3i Description: Additional/Optional Exams: Radiological Evaluation Page 7 of 54 Category: 94874-50 Unit of Measure: Each Unit Price: $ %S Line: 1.14 ceo Number of Units: 200 Total: $ 45, UVL) Description: Additional/Optional Exams: Flexible Sigmoidoscopy Category: 94874-50• Unit of Measure: Each Unit Price: $ J%7 Line: 1.15 Number of Units: 10 Total: $ 5 r 757 Description: Additional/Optional Exams: Colonoscopy Category: 94874-50 Unit of Measure: Each Unit Price: $ v .J / Number of Units: 10 Line: 1.16 Description: Additional/Optional Exams: RPR Category: 94874-50 Unit of Measure: Each Unit Price: $ /0. 3 Ci Number of Units: 1 Line: 1.17 Total: $ oz / /'� Total: $ / • 6---U Description: Additional/Optional Exams: 24 Hour Hotter Monitor Category: 94874-50 Unit of Measure: Each Page 8 of 54 Unit Price: $ 3 3 Number of Units: 15 Total: $ S/ 9o2 Line: 1.18 Description: Additional/Optional Exams: Mantoux Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 15 Line: 1.19 Number of Units: 550 Total: $ i o� SG Description: Additional/Optional Exams: Flu Shot Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.20 .`J Number of Units: 700 Total: $ `7`'J Description: Additional/Optional Exams: Hazardous Material Team, Dive Team, TRT Physical Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.21 Number of Units: 170 Total: $ •5) 6 Description: Additional/Optional Exams: Bilirubin Direct and 'focal Category: 94874-50 Unit of Measure: Each Unit Price: $ % O ' c)-<) Number of Units: 170 Total: $ Page 9 of 54 Line: 1.22 Description: Additional/Optional Exams: Cholinesterase Category: 94874-50 Unit of Measure: Each Unit Price: $ %7 . CO Line: 1.23 Number of Units: 170 Total: $ / /ca- o-o Description: Additional/Optional Exams: Heavy Metal Screening Quantitative for Pb (Lead), As (Arsenic), Hg (Mercury) Category: 94874-50 Unit of Measure: Each Unit Price: $ U C Number of Units: 170 Total: $ `' Line: 1.24 Description: Additional/Optional Exams: Tonometry Category: 94874-50 Unit of Measure: Each Unit Price: $ /0 . J Number of Units: 170 Total: $ // 7 51 S Line: 1.25 Description: Hepatitis A Immunizations - First Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 50 Total: $ 3, 11 Gr--C ) Page 10 of 54 r Line: 1.26 Description: Hepatitis A Immunizations - Second Injection Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.27 Number of Units: 50 Total: $ 3 '4-(Pr) Description: Hepatitis 13 Immunizations - First Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ 6 Line: 1.28 Number of Units: 50 Total: $ 5. (J-)-v Description: Hepatitis B Immunizations - Second injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ 6,6 Line: 1.29 Number of Units: 50 Total: $ Description: Hepatitis B Immunizations - Third Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each o-d Unit Price: $ Line: 1.30 Number of Units: 50 Total: $ Page 11 of 54 Description: Hepatitis A and B Combined (TWINRIX) - First Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /C) Line: 1.31 co -el Number of Units: 50 Total: $ Description: Hepatitis A and B Combined (TWINRIX) - Second Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /UZ Line: 1.32 Number of Units: 50 Total: $ Description: Hepatitis A and B Combined (TWINRIX) - Third Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ / )/ Line: 1.33 u-f1 Number of Units: 50 Total: $ /� s Description: Additional/Optional Exams: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ T Line: 2 Number of Units: 400 Total: $ /mac/ Description: GROUP 2 - POLICE ANNUAL PHYSICAL EXAMINATION SERVICES, INCLUDING HEPATITIS A and B PROGRAM. Page 12 of 54 Line: 2.1 Description: Basic Physical (including lab work, visual exam, and Audiological Exam) Category: 94874-50 Unit of Measure: Each Unit Price: $ j Line: 2.2 Number of Units: 1,100 Total: $ 6" 'P"1—r) z Description: Pulmonary Function Test Category: 94874-50 Unit of Measure: Each Oi Unit Price: $ Number of Units: 50 Line: 2.3 Description: Electrocardiogram (EKG) Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.4 Total: $ 3') Number of Units: 1,100 Total: $ 9, 50O Description: PPD Skin Test (Mantoux) Category: 94874-50 Unit of Measure: Each Unit Price: $ / 7 Line: 2.5 Number of Units: 1,100 Total: $ / / 7«v Page 13 of 54 Description: Additional/Optional Exams: Radiological Evaluation Category: 94874-50 Unit of Measure: Each Unit Price: $ 7� Line: 2.6 o-d Number of Units: 800 Total: $ &CI ' ' Description: Additional/Optional Exams: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.7 Number of Units: 100 Total: $ aZ 0r (711 c) Description: Additional/Optional Exams: Echocardiogram Category: 94874-50 Unit of Measure: Each Unit Price: $ ' �5 Line: 2.8 Number of Units: 100 Total: $ Description: Additional/Optional Exams: Thallium Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.9 Number of units: 75 Total: $ Description: Additional/Optional Exams: Exercise Muga Stress Test Page 14 of 54 Category: 94874-50 Unit of Measure: Each Unit Price: $ 0--0 Line: 2.10 Number of Units: 1 Total $ 6='4"--61 Description: Additional/Optional Exams: Stool Hematest for Occult Blood Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.11 Number of Units: 1. Description: Additional/Optional Exams: Pap Smear Category: 94874-50 Unit of Measure: Each Unit Price: $Jb •Sv Line: 2.12 Total: $ 'v Number of Units: 10 Total: $ Description: Additional/Optional Exarns: Mammogram Category: 94874-50 Unit of Measure: Each Unit Price: $ /7s Line: 2.13 u-e) Number of Units: 50 Total: $ `J U Description: Additional/Optional Exams: CA 125 Category: 94874-50 Unit of Measure: Each Page 15 of 54 Unit Price: $ Line: 2.14 Number of Units: 1 Total: $ Description: Additional/Optional Exams: PSA Category: 94874-50 Unit of Measure: Each Unit Price: $ !L Line: 2.15 Number of Units: 600 Total $ 0-6 Description: Additional/Optional Exams: Comprehensive Hearing Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 33 Number of Units: 10 Line: 2.16 �b 0.0 Total: $ Description: Additional/Optional Exams: 24 Hour Bolter Monitor Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.17 Number of Units: 50 Total: $ Description: Additional/Optional Exams: HBSAB Titer Category: 94874-50 Unit of .Measure: Eac Unit Price: $ Number of Units: 1 cryi Total: $ /5 Page 16 of 54 Line: 2.18 Description: Additional/Optional Exams: Flexible sigmoidoscopy Category: 94874-50 Unit of Measure: Each Unit Price: $ 7�6.- Number of Units: 1 Line: 2.19 Description: Additional/Optional Exams: Tetanus Booster Category: 94874-50 Unit of Measure: Each Unit Price: Line: 2.20 Total: $ 7-6 Number of Units: 150 Total: $ Si 6 c) Description: Additional/Optional Exams: Bilirubin Direct and Total Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.21 Number of Units: 1 Total: $ Description: Additional/Optional Exams: Cholinesterase Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 1 Line: 2.22 Total: $ (:::) Page 17 of 54 Description: Additional/Optional Exams: Heavy Metal Screening Quantitatative for Pb (Lead), As (Arsenic), Hg (Mercury) Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.23 Number of Units: 1 Total: $� Description: Additional/Optional Exams: Tonomctry Category: 94874-50 Unit of Measure: Each Unit Price: $ / - 6-6 Number of Units: 1 Total: $ Line: 2.24 Description: Additional/Optional Exams: R.P.R. Category: 94874-50 Unit of Measure: Each Unit Price: $ ifj) Line: 2.25 Number of Units: 1 Total: $ Description: Additional/Optional Exams: Blood Type Category: 94874-50 Unit of Measure: Each Unit Price: $ 30 Line: 2.26 Number of Units: 1 Description: Hepatitis A Immunizations - First Injection Total: $ "--3O Page 18 of 54 In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.27 Number of Units: 75 Total: $ 5-2 G'-- Description: Hepatitis A immunizations - Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ �' U Line: 2.28 Number of Units: 75 Description: Hepatitis B Immunizations - First Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ YiD Line: 2.29 Total $ / Number of Units: 75 Total: $ J fT Description: Hepatitis B Immunizations - Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.30 ho Number of Units: 75 Description: Hepatitis B Immunizations - Third Injection In accordance with Specifications Category: 94874-50 Total: $ T"/� Page 19 of 54 Unit of Measure: Each Unit Price: $ Number of Units: 75 Line: 2.31 Description: Hepatitis B Immunizations - Third Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ A4'0 Line: 2.32 Number of Units: 75 Total: $ .5 C77) Total: $ Description: Hepatitis A and B Combined (TWINRIX) - First Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: S /0 yL Line: 2.33 Number of Units: 75 Total: $ 7/ kCU Description: Hepatitis A and B Combined (TWINRIX) - Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure:Each Unit Price: $ Line: 2.34 /' ' Number of Units: 75 c`-t7r Total: $ 7, i-r-G) Description: Hepatitis A and B Combined (TWINRIX) - Third Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /0 Number of Units: 75 Total: $ 7/ 7 0'7) Page 20 of 54 i 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. ■ Mercy Hospital is the recipient of the American Nurses Credentialing Centers prestigious Magnet award for excellence in nursing services (2010). • Mercy Hospital was named in U.S. News America's Best Hospitals 2009-2010. • 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 years 2006, 2007 and 2008 and named hospitals in the top five percent as HealthGrades Distinguished Hospitals for Clinical Excellencee' • 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. ■ October 20, 2010: Mercy Hospital is among the top 10% in the nation in Spine Surgery, Stroke Care, and Pulmonary Services according to HealthGrades comprehensive annual study. The following areas of care received Five -Star Ratings: Treatment of Heart Attack & Heart Failure, Overall Orthopedics, Joint Replacement, Total Knee Replacement, Spine Surgery, Back and Neck Surgery, Stroke Care, Pulmonary Care, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Sepsis and Respiratory Failure. 2010 NOT -FOR -PROFIT CORPORATION ANNUAL REPORT FILED DOCUMENT# N09556 Secretary'of State Entity Name: MERCY MEDICAL DEVELOPMENT, INC_ Current Principal Place of Business: 3663 SOUTH MIAMI AVENUE MIAMI. FL 33133 US New Principal Place of Business: Current Mailing Address: New Mailing Address: % LEWIS W FISHMAN 9130 S DADELAND BLVD #1121 MIAMI, FL 33156 FEI Number: 59-2789194 FEI 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 9130 S. DADELAND BLVD. MIAMI, FL 33156 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 Title: 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 - nn an attachment with all other like empowered. SIGNATURE: JOHN HAZEL CD 03/04/2010 Electronic Signature of Signing Officer or Director Date www.sunbiz.org - Department of State Home Contact Us E-Filing Services Document Searches Forms Page 1 of 2 Help Previous on List Next on List Events Name History Return To List Detail by FEI/EIN Number 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 MIAMI FL 33133 Q.:�,. ,1,.,. , r—nrnnc.c n.; i i rot -in i n www.sunbiz.org - Department of State Page 2 of 2 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 02/04/2008 -- 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 View image in PDF,format 1 View image in PDF format 1 View image in PDF format View image in PDF format l View image in PDF format View image,in PDF format View image in PDF format J View image in PDF format View image in PDF format View_imagein PDF format View image in PDF format View image in PDF format_ View image in PDF format J View image in PDF format J 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 Note: This is not official record. See documents if question or conflict. Previous on List Next on List Events Name History Return To List I Home 1 Contact us I Document Searches 1 E-Filing Services 1 Forms i Help I Copyright© and Privacy Policies State of Florida, Department of State T.++.,,•//,,,,,,,,, ,,,,,,, L.:.� ,.. �. /�.. r:.,.+�/.......d o+ o.,o`J.,..+:.,.,=TIRTL.'rr 2, ,,,, .a..� .-,.�„-, L,�,--T�i(1000�,P.;,, 1 1 /017(11 rl 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, Audiology, 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 1. Camp III, MSN, RN Family Practice Z. Rafael Abad, M.D. Ines Braceras, M.D. Rheinchard Reyes, M.D. Cardiology Mahboobeh Goltapeh, M.D. Audiology Constance.H. Cabeza, Au.D. Maria V. Alvarez Internal Medicine Humberto Machado, M.D. Max Pazos, M.D. Radiologists South Florida Medical Imaging Staff Nurses Gonzalo I. Arcentales, R.N. 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@aol.com Administrative Nursing Summary of Qualifications IS Knowledge and experience in hospital operations, IR Demonstrates cost management in strategic planning, program development and accordance with hospital priorities and fiscal management of multiple departments. mission N I Track record in establishing strong collaborative IN Accreditation and Program Certification relationships between, Physicians, Nursing and Patient Relations 1151 Presentation Skills IN Productivity management 11 PC skills include (Database, Internet, and Microsoft Office, Exactcost ABC/ABM Management System, Kaufmann Hall Budget Software and Kronos/Visionware productivity module. 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 2001-2004 1994-1999 1972-1975 TEACHING AFFILIATIONS 6/2006-Present Barry University School of Nursing Miami Shores, FI Assigned to instruct: • Nursing 674 Financial Strategies for Nurse Executives • Nursing 675 Human Resource Management for Nurses 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 Oxygen 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 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. • . 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 ofthe 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 anc1 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 departments 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 hrternational 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 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. • 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 ll i recto r 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 andfor 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 Departments, and the International Travel Clinic —providing education and immunizations for persons traveling internationally. Responsible for staffing and fiscal management of these departments, performance improvement activities and program certifications. The Director is also responsible for Capital Equipment Purchasing. 1 am a member of the Magnet Nursing Leadership Task Force as well as a member of the STEMI 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 Clinic, 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 [I, III and [V. Reviewer for Cardiac Rehabilitation Scope of Nursing Practice. PACU, 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 -I LOOpm. 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, III and IV. Surgical Intensive Care Mercy Hospital Miami, Florida Charge Nurse 3:00pm — 11: pm MEMBERSHIPS • ANA/FNA • American Organization 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 # 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. Radiology Management, 31(3), 9-12. American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) — Diversity in Exercise Programming: Project IDEA, 101h 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 Delivery 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 Rehabilita tion. Looking ahead... Moving Forward November 6-9, 1991 Long Beach, California Educational Meetings and Seminars 11/04/2002 Mentoring Nurses 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 OF • DEPARTMeNT.tQF-:!11.ALT11 . • •DATE 'LICENSE 04114120110' STERED NURSE ow has met all requlrements of id rules ofthe state of FIorida Date APR1L3o,o PH4.1:11:CAMP'• '11'1V11A1.141AYENIQE 33133 po.VERN(D)R - -RNV87;902 CONTROL NO 630 1208. • • . • -• • • • •• STATESURGEON GENERAL 1=):[$PLAY IF REQUfRED BY LAW 114nin #III rernmmrnbatton of tly lNarrnitg, o&rb of Trn,wtrr,i IIati rnnfrrrrrl nn Rrubrn Jniju Lamp itt the hrgrET.nf flta0t of'rtrnn toNitring in rrrognitinn of Op zati, ifFtrinrg ftttfilinunt of 1.4r• rrgnirrrnmth p. rtaining to t{fli begat'. Csiuen Bag of Mall, hxun Offnini tnb anb. 3finnr in i tami'fjnre�, Bait, CImtnt j, fnrtho. 72/11 Bran Hospital September 15, 2010 To Whom It May Concern: RE: Zoilo R. Abad, MD In response to your request for status information on the above referenced physician, our records indicate the following: STAFF CATEGORY: Senior Attending DEPARTMENT: FAMILY PRACTICE SPECIALTY: FAMILY PRACTICE DATE OF APPOINTMENT: 7/22/2004 STATUS: Active If I can be of further assistance, feel free to contact me at the address below or by telephone at (305) 285-2771. Sincerel yours, 3b\ Silvia Dire and Me SO/mso T-d iz, H 'cal Jai I' 7-1ir VHSA, RHI , CPMS th Information taff Services en Xdd 13Cb3Sd1 dH WEOC:8 OTO2 ST de Page 1 of 1 Current Date: 9/15/2010 Data File Release Date: 09/07/2010 Drug Enforcement Administration (DEA) Datafiles -Both Registrant Profile Aar ABAD, ZOII.O R MD Address: 3661 SOUTH MIAMI AVENUE SUITE 1001 MIAMI State and Zip: FL 33133 DEA Number: BA6788458 Business Activity Code: C Business Activity Sub Code: 0 Drug Schedule: 22N 33N 4 5 Drug Codes: Expiration Date: 6/30/2012 Payment Indicator: P __..._http-s-//wwvrdeanilmber corn/Library/DEA/SearcliRestiltsPrintasp 9/15f2O14 z • a XH3 13Ci'I3Sd1 dH WHOE:B OTOZ ST daS 11314 of q Ztiia taitteibttd,•�. is a Diplomate of this Board and having met its continuing requirements is hereby Biptomate 2008-2015 )f Healthcare Practitioner License Printer Friendly Detail Information Display Page 1 of I License Verification Data As Of 9/15/2010 ZOILO RAFAEL ABAD LICENSE NUMBER: ME82104 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date License Original Issue Date 1/31/2012 03/29/2001 Discipline on File NO Address of Record MERCY PROFESSIONAL BUILDING, S 3661 SOUTH MIAM1 AVENUE *1001 MIAMI, FL 33133 UNITED STATES 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. https://ww2.doh.state-.fl.us/IRMOOPRAES/prasindi print_report.asp?LicId=76699&ProfNBR=150... 9/15/2010 IdenttfIcation Number 111267 AmeripeRI5perdefFerOy,Medicine Tel 1l88et047Odkr. SU0130:Ciiiiter 1,1377401-7437 Home Page svww:lbeibtrmorg Zell° Rafael Abad M.D. Not.,VatfdlorNorlfkaLtrrPu SOS STATE OF FLORIDA AC# 37 1 ::0461 DEPARTMENT OF HEALTH DIVISION OFMEOICAL QUALITY ASSURANCE ;:CONTROL NO :. 1 LICENSE NO. 12f23/2009 ME 82104 302205 The MEDICAI-DOCTOR named below • has met all requirementsof Me taws and rules of the state of Florida. . Expiration Date[ JANUARY 31`, 2012 MI e - •ice' L ABAD EE SIGNATUR FL Dept. of Health - Print This Page Practitioner Profile Information in this profile has been verified by the practitioner. ZOILO RAFAEL ABAD Primary Practice Address ZOILO RAFAEL ABAD MERCY PROFESSIONAL BUILDING, S 3661 SOUTH MIAMI AVENUE #1001 MIAMI, FL 33133 UNITED STATES Medicaid This practitioner does participate in the Medicaid program. LICENSE NUMBER: ME82104 Profession: MEDICAL DOCTOR Year Began Practicing: Not Provided Expiration Date: 1/31/2012 Status: CLEAR/ACTIVE Staff Privileges This practitioner currently holds staff privileges at the following hospital/medical/health institutions: Institution Name MERCY HOSPITAL INC. City MIAMI State FLORIDA Institution Name UNIVERSITY OF MIAMI HOSPITAL City MIAMI State FLORIDA E-Mail Address Please contact at: rafy_abad@yahoo.com Other State Licensure This practitioner has indicated the following additional state licensure: State NEVADA Profession MEDICINE State NEVADA Profession MEDICAL DOCTOR Education and Training Institution Name Dates of Attendance Graduation Date Degree Title PONTIFICIA UNIV CATOLICA MADRE Page 1 of 4 https://ww2.doh.state.fl.us/irm00Profil ing/print_report.asp?LicId=76699&ProfNBR=1501 &printe... 9/15/2010 FL Dept. of Health - Print This Page Institution Name PONTIFICIA UNIVERSIDAD CATOLIC Dates of Attendance - Graduation Date 1/29/1994 Degree Title MD Other Health Related Degrees Thispractitioner does not hold any -additional health related degrees. Professional and Postgraduate Training This practitioner has completed the following graduate medical education: Program Name SAINT MARY OF NAZARETH HOSPITAL Program Type RESIDENCY Specialty Area FP - FAMILY MEDICINE Other Specialty Area City CHICAGO State or Country ILLINOIS Dates Attended From 08/01/1997 Dates Attended To 07/31/2000 Academic Appointments This practitioner does not currently hold faculty appointments at any medical/health related institutions of higher learning. Specialty Certification This practitioner holds the following certifications from specialty boards recognized by the Florida board which regulates the profession for which he/she is licensed: Specialty Board AMERICAN BOARD OF FAMILY MEDICINE Certification FP - FAMILY MEDICINE Page 2 of 4 Financial Responsibility I have hospital staff privileges and I have professional liability coverage in an amount not less than $250,000 per claim, with a minimum annual aggregate of not less than $750,000 from an authorized insurer as defined under s. 624.09, F. S., from a surplus lines insurer as defined under s. 626.914(2); F. S., from a risk retention group as defined under s. 627.942, F.S., from the Joint Underwriting Association established under s. 627.351(4), F. S., or through a plan of self insurance as provided in s.627 .357, F.S. Criminal Offenses The criminal history information, if any exists, may beincomplete; federal criminal history information is not available to the public. Information is verified by DOH at the time of initial licensure through the FDLE and FBI. Changes after initial licensure may be self -reported by the practitioner or updated based on a report received from FDLE. DOH conducts statewide criminal background checks every two years, immediately following a renewal cycle for the practitioner. This practitioner has indicated that he/she has NO criminal offenses. Information provided has been verified through a criminal records check as of 6/25/2010 3:11:41 PM. https://ww2.doh.state.fl..us/irmO0Profiling/print_report.asp?LieId=76699&ProfNBR=1501 &printe... 9/15/2010 07-27-10 : 10 29AM : # 2/ 5 12.;;;;:7-':-,h. • • D Et*RtMpORORMgAL I H QUALITY:,A4§P,1349gDATE bqT,i36.13N.b. 01/1Z/20'10 The 1140-,316A.L.i*30-rbi'.::1:' namedbeiow'fQ m 6f a Iri=e46 ire m ents of 1;4%40,rui4 pl'tii6:.sJ4te of Florida. RY 31, 2012 760 PONCE p ••,3- . • .•4 , , COLGIS FL'33i34.. • ;,tLi24;h4c44 0 OVONOR ffii.o'A4. Viamon(0q304:ii MI,:rp.'z14...p!.H...:7.7,.., . , ..:. ,.- STATE SURQION QENEf3A \1� 31nto Maria laraterao, 1113. having met all its requirements is hereby certified to be a Executive Director adc Secretary ilijnotitate of this Board for the period 2004-20 1 1 President 07-27-10;10:29AM; # 3/ 5 Professional Experience: Residency: Education: Ines M. Braceras. M.D. Curriculum Vitae 1161 SW 13th Street Miami, FL 33129 Ph: 305-857-0303 Cell: 305-807-0626 Email: bracerasmd@yahoo.com Ines M. Braceras, 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 Clinical 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 07-27-10; 10:29AM; Achievements/ Affiliations: Licensure/ Certifications: • Fred Ester 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 4 4/ 5 STATE OF FLORIDA DEPARTMENT,OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO (CONTROL NO. • 11/10/2009 •-ME 77894 - . 294379 The `MEDICAL. DOCTOR `.... named'be ow`has met afl'requirements of e laws arid-rufes of the state of Florida: Expfiatlog.Date JANbARY 31, 2012. RHElNC'HARD ROBERTO'REYES 3157.SW 21 STREET MIAMI; FL 33945 UNITED STATES s°;M. ViamontlaRos, M D M P, STATE SURGSON GENERl.L 0 L -U LICENSE NO. EXPIRATION DATE:-JANUARY 31, 2012 Your license number is ME 77894, •please use it id all correspondence withyour hoard/council. Each licensee is solely responsible for notifying the llicensee's current mailing address and practice:location address, If you have not received your renewal notice.90 days prior to the expiration call (8501 488-0595. - � ... - .. Use this section in reportname change.' Name changes require legal documentation showing the name change. Please make sure theta phowcopy accompanies this form: a'marriage license; a:divorce'decree or.a court order. A iirlycr s license .or social security card is eat considered legal d Medical Quality -assurance offers you the convenience of several •online services. Thcseservices give you the ability -to renew your license, update location addresses andupdate your profile. information.• 1. Go to www.fl healthsonree.eom 2. Click on Licensee/Provider 3. Click on Practitioner Login. 4= Selectyour profession 5. Enter.the account1D and -password that was provided to you on your initial license and click on°Login".. G if you do VOL know your account ID and password,'click on ^Get Loginitelp".or call our Customer Contact Center at.(850 MAIL TO: DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE LICENSING AND AUDITING. SERVICES UNIT: P.O. BOX 6320 • TALLAHASSEE, FLORIDA'32314-6320 O NAME CHANGE (ATTACH LEGAL DOCUMENTATION) FROM:. _ LAST TO::.. .- FIRST - .MIDDLE LAST FIRST...,..MIDDLE'_ .DH'2103.5/98 . 0, uJ •rs z>� 0 the department in wri• date shown on this lie! of one of the following octunentation.- your mailing and prac 88-0595 fo -LIJ-IU, I L�4yYM; Founded 1969 James C. Pr ffet; 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, F_d.D. Vice President Examination Administration and Credentials Joseph tV Tollison, M.D. Senior Advisor to the President Martin A. Quan. M.D. Senior Advisor to the President Roper( F. Avant, M.D. Executive Director Emeritus Paal R. Young. M.D. Executive Director Emeritus 222S Yaan4 !hive 1_exinalrrrt. KY 4O5ti5-4294 TO: itt O) `t95•571111 c>;571 269_5626 Fax; (8591 335-75(11 (859) 3 ;5(19 :be A eurh»n. !!rural a/. A.mericari Board. of Family I ' icinc, Inc. September 30, 2008 To Whom It May Concern: 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. Each physician (Diplomate) fulfilled the obligation of maintaining a full and unrestricted medical license, earning 300 hours of continuing medical education (CME), 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 1 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 Diplomate 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 7/ -GO - IV '11�4'yYM; ) 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 01/2009 Healthcare Practitioner License Printer Friendly Detail Information Display Page l of License Verification Data As Of 7/26/2010 MAHBOOBEH GOLTAPEH LICENSE NUMBER: ME50341 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date License Original Issue Date 1/31/2012 04/27/1987 Discipline on File Public Complaint NO NO Address of Record 3661 S 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. alitg o ahis is to cfertifi) t 7.11InhboDbefi, 6oitopeli 13etn3Electeb FELLOW August 30, 1996 lartsiDntr ;errTT 2, 114CORPORATED 1936 ATTESTS THAT lihnulnii. (1tpth HAS MET THE REQUIREMENTS OF THIS BOARD DESIGNATED A DIPLOMATE CERT1F1ED1N THE SPECIALTY OF IS HEREBY INTERNAL MEDICI E Dart 13543 SEPTEMBER 13, 1989 tYaNa >00. .tt J itiailhanhr4 &hap 1,ers ‘te,e7, deceede INI3V.C.9.201C, 11:0C. 305E54E61E MIAMI 1-1E1-`1'..T1,1G, MID ..SPEECH f16707 DIVISION OF MEDCAL QUALITY ASURANCE • • • ••••••. •_..::• The AUOJOLOIST tliet Il equuernerLs of ' - Eq0VB Ejk: CONSTANCEHCABEZA UNITEDTATES D 'STA1 L SUkCEON ::--- - DAE' - - .6618t, 40:::'"..." 'I. ' ''' 'N: rac N6...-- ..- .:‘::: C -,-- '• ,... *Iffiliiiii9,-:.....; ,. 4:, ,..,., '-: .. A0 19 "..: .,-3pk.711E:,.. ',.. ..:,',- .. ;,.-..- 1 1 cETN sE, NQ:-: ,.., ;., : •,-,-;, ...,CONTFOL:NC) 12/17/200-9 7' ''.- --- .':' NY-'51..T. ''.. - ' .. . ', .....r-:.52i.. CONSTANCE H. CABEZA, AU.D. BIRTH: April 4, 1946, Ringgold, Georgia MARRIED: Husband, Daniel CHILDREN: Denise, Daniel EDUCATION: Ringgold High School University of Tennessee,1968, BS University of Tennessee, 1969, MA University cif Florida, 2000, Au.D. Certification: Certificate of Clinical Competence by American Speech, Hearing and Language Association Board Certified in Audiology Fellow of Audiology, American Academy of Audiology Certified Audiologist in State of Florida Occupational Hearing Conservationist Florida Teacher's Certificate In Speech Pathology, 1971-81 CLINICAL POSITIONS: Director of Miami Hearing and Speech Center March 1974 to present VA Consultant, 1985-90 VA Consultant for Pension and Compensation Claims, 1998-1999 Clinical Audiologist and Electronystagmography Specialist: October 1972 to March 1974 Emptoyer: Fredrick W. Pullen, II, M.D. Vocational Rehabilitation Counselor: October 1971 to October 1972 Clinical Audiologist and Instructor Temple University Medical School December 1969 to August 1971 Research Assistant, January 1969 to December 1969 Carl W. Asp, Ph.D., University of Tennessee PROFESSIONAL ORGANIZATIONS: American Academy of Audiology American Speech, Hearing and Language Association Florida Language/Speech and Hearing Association Florida Academy of Audiology Society of Medical Audiology Treasurer, 1977 to 1981 Miami Association of Communication Sciences International Society of Audiology National Rehabilitation Association Honda Rehabilitation Association Dade Chapter, Secretary, 1976 Hearing Conservation Association Treasurer 1976 to 1981 American Auditory Society American Academy of Otolaryngology, Associate Member American Academy of Dispensing Audiologist APPOINTMENTS: Stag of Florida, Advisory Council of Speech - Language Pathology and Audiology, June 1984-1990, Chairman, 1986-87 PROFESSIONAL COMMII i tES: VA Consultant, Audiology and Speech Pathology Service, 1985-1990, 1993-94, American Speech and Hearing Association, Committee on Hearing Conservation and Industrial Audiology, 1976, 1977, 1978 ASHA — Task Force on Audiological Relative Work Values, 1993 Congressional Acton Contact 1976, 1977, 1978, 1979 Florida Language/Speech and Hearing Association Committee on Professional Opportunities, 1978 FLASHA — Medicare, Medicaid Committee, Chairman 1980 Local Arrangements (Publicity Chairman) FLASHA Convention, 1984 AWARDS AND RECOGNITION: Honors Award — American Academy of Otolaryngology, October 1985 Who's Who in the South and Southwest, 1979 International Who's Who of Women, 1988 Who's Who of Women, 1986 CIVIC ACTIVITIES: President Alpha Delta Pi Alumnae Ascreiation of Greater Miami, 1976-77 St Stephen's School and Home Association Auction Donations Young Patronesses of the Opera Junior Opera Guild, Sponsor 1995,1996 Financial Secretary, 1996 Yearbook, 2000 Historian 2003 EXHIBITS: Evaluation and Treatment of the Dizzy Patient (With Fredric W. Pullen, II, M.D.) Displayed: Florida Medical Association Meeting: May 1974 (First Award) Displayed: American Speech and Hearing Association Annual Meeting. November 1974 Displayed: American Geriatric Society Meeting: April 1975 Displayed: Southern Medical Association Convention: November 1975 Hearing Test (with Lennon Adams, MA and Fredric W. Pullen, II, MD) Displayed: Florida Medical Association, 1977 Award: Honorable Mention Recent Advancement In diagnosis and Treatment of Ear Disease (With F.W. Pullen, II, M.D., Gary Rodriguez, MS and Natalie Fernandez -Roque, MA Displayed: Florida Medical Association Meeting, May 1981 Displayed: American Academy of Otolaryngology, New Orleans, September 1081 Displayed Southern Medical Association Meeting, November 1981 (First Award) MOVIES: "Guide to Electronystagrixagraphy" 1975 (Video Tape) "HEARSAFE" BNA Communications, Inc., Rockville, Maryland, 1994 (Video Tape) BIBLIOGRAPHY: 'The Neuro-Otologic Approach to the Dizzy Patient", (With Fredric W. Pullen, II, and M.D.) Newsletter of Society of Medical Audiology, III, Issue 3, P.1 (Spring, 1976) "Sudden Hearing Loss in Divers and Fliers" (With Fredric W. Pullen, II, and M.D.) The Laryngoscope, Vol. LXXXIX, No.9, Pp.1973-1377, (September 1979) Clinical E$ectronvstagmography, (with Fredric W. Pullen, 1I, M.D.) Amplaid, S.p.A. Milan, Italy, February 1983, Sensus 72. "Medico -Legal Aspects of Hearing Loss and Vertigo" (With Fredric W. Pullen, II, M.D.) Audiology, Grune & Stratton, Inc. New York, August 1983. "Hear This!" Cause and Effect vol. V, No. 2, Oct- Nov. 1991, P.8. (y1 "Cochlear Implants" (with L. Grobman, M.D., F. Pullen, N. Fernandez - Roque, M.Canal) Journal of Florida Language, Speech, and Hearing Association, Vol. 114, p.20, 1994. PRESENTATIONS: Measurement of Operant Conditioning of the Vocalization of Pre'hool Deaf Children (with Carl Asp). Presentedtat the Acoustical Society of America Convention,1070 "The Deaf Child", Post -Graduate Seminar in Otolaryngology for the Family Practitioner, Department of Otolaryngology, University of Miami School of Medicine, Miami Beach, FI, September 1972 "Clinical Electronystagmography Workshop", West Palm Beach, FI. April 1.974 "Clinical Electronystagmography workshop", Las Vegas, Nevada, November1974 "The Neuro-Otnlogic Evaluation and ENG workshop", Tampa, Florida, January 1975 "Clinical Electronystagmography Workshop", Charlotte, North Carolina, August 1975 "Medico -Legal, Aspects of Hearing Loss", (with Frederic W. Pullen, II, MD and Harry W. McCurdy, MO), American Academy of Ophthalmology and Otolaryngology, Dallas, Texas, September 1975 "Hearing conservation for Technicians", Instructor, Mercy Hospital, Miami, Florida, October 1975 "Clinical Electronystagmography Workshop", Mercy Hospital, Miami, FI, November 1975 "The Neuro-Otoiogic Evaluation and Workshop". Washington, November, 1975 "Medico -Legal Aspects of Hearing Loss", guest speaker for Medical Audiology Society, November 1975 "Clinical Applications of the Audlo-Vestibular Examination", Instructor, American Speech and Hearing Association, Annual Convention Short Course, November, 1975 "Hearing Conservation for Technicians", Instructor, Mercy Hospital, Miami, Florida, February 1976 "Computerized Axial Tomography in Otolaryngology: 10"' Colorado Medical Audiology Workshop, Vail, Colorado, March, 1976 "Etectronystagmography Workshop", Emerson College, Boston Ma. June 5-6, 1976 "Clinical 8ectronystagmography", Dayton, Ohio, June 11-12, 1976 "Clinical Electronystagmography", Chicago, IL, July 30-31, 1976 "Short Course in Objective ENT Test Procedures", Instructor, The University of Connecticut Health Center, Farmington, CT, September 1976 "Medico -Legal Aspects of Hearing Loss" (with Fredric W. Pullen, II, MD) American Academy of Ophthalmology and Otolaryngology, Las Vegas, Nevada, October 1976 Basic ENG Seminars to Temple University Graduate Students, Philadelphia, Pennsylvania This is to certify that Constance Cabeza has completed the Rittman Participants Protection Education for Research Team online course, sponsored by the National Institutes of Health (NIR), an 04/01/2007. This course included the following: • key historical eventsand current issues thatimpact guidelines and legislation on human participant protection in research. . ethical principles and guidelines that should. assist in resolving the ethical issues inherent in the conduct of research with human participants. • the use of key ethical principles and federal regulations to protect human participniits at various stages in the research process. • a description of guidelines for the protection of special populations in research. a definition of informed consent and components necessary far a valid consent • a description of the role of the IRB in. the research process. • the roles, responsibilities, and interactions of federal agencies, institutions, and researchers in conducting research with human participants. National Institutes of Health A Service of the National Cancer Institute http://cme.cancer.gov/cgi-bin/cms/cts-certS.p1 4/ 1 /2007 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 1/31/2011 License Original Issue Date 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 :'mmediately upon a change to our licensing and enforcement database. Acg215695 STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. 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