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Exhibit 7
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: Internship: 06/24/66- 06/23/67 Residency: 06/24/67- 02/28/69 02/26/71- 06/30/71 Bachelor of Science. Instituto del Vedado, Havana, Cuba. Licentiate in Medicine and Surgery. University of Salamanca, School of Medicine, Spain 1965 University of Miami, School of Medicine and Jackson Memorial Hospital, Miami, Florida. Straight Medicine Internship. University of Miami, School of Medicine and Jackson Memorial Hospital, Miami, Florida. Resident inMedicine (after completion of Military Service, vide infra). Fellowship: 07/01/71-06/30/73 University of Miami, School of Medicine and Veterans Administration Hospital, Miami, 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 04/69-10/69 Major, U.S. Army Medical Corps. Assigned to the 3'a Field Hospital, Saigon, Republic of Vietnam. Chief of Internal Medicine Clinic. Captain, U.S. Army Medical Corps. Assigned to the 9th Infantry Division, Republic of Vietnam. MEDALS AND CITATIONS: Bronze Star Medal National Defense Service Medal Vietnam Campaign Medal Army Commendation Medal Vietnam Service 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 Co -Director, Amoral Symposium, Greater Miami Society of Echocardiography. 1981- present Co- Director , Annual Symposium, Presented by Miami Cardiac & Vascular Institute. 1999 - present Advisor, Mercy Hospital, Heart Failure Program. MEDICAL SOCIETIES: 2002 Fellow of the American Society of Echocardiography 1979 Fellow of the American College of Cardiology 1973- present Member of the American College of Physicians 1976 Fellow of the American College of Physician 1981 Fellow of the American Heart Association Fellow of the Council on Clinical.Cardiology 1971- present Member of the Dade County Medical Association 1975 Fellow of the American Society of Internal Medicine 1974- 1980 Fellow of the American College of Angiology Founding President, Greater Miami Society of Echocardiography CERTIFICATONS 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. VoLXX, No. 1, January1972. Humberto Machado, M.D.; Louis Lemberg, M.D.; His Bundle Recordings in Patients with Acute inferior Wall Myocardial Infarction. Clinical Research. Vol. XX, No. 1, pg. 23, January 1973. 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 II (Mobitz) Block Occurring During Acute Myocardial Infarction. American Heart Association 45th 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) 6) 7) 8) Humberto Machado, M.D. ; B. Befeler , M.D.; David E. Wells , M.D.; Richard J. Thuurer, 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, 22°d Annual Scientific Session. San Francisco. February 1973. Curriculum Vitae Page 4 9) 10) 11) 12) 13) 14) 15) 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 Athersclerosis (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. Chabine, 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. 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) 18) 19) 20) 21) 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). Humberto Machado, MD.; Current Application of Tranesophageal Echocardiography. (Mercy Medicine- Vol 3, No 3, 1992). Humberto Machado, MD., FACC,; Alberto Interian, MD., FACC,; Heart Failure Sudden Cardiac Death; Going Beyond Drugs. March 8, 2003 Humberto Machado, MD, FACC, FASE; Alberto Interian, M.D., FACC; Cardiac Resynchronization Therapy 2005 Heart Failure Drugs and Devies. 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 Hospital 651 East 25th Street Hialeah, Florida 33013 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 Page 1 of 1 hftn•//nhrn nihtrainincr nnrn icarv/ rt „i 9'=d7'?RS(1 '7/1 [/2111 n Healthcare Practitioner License Printer Friendly Detail Information Display Page 1 of License Verification Data As Of 7/26/2010 MAX PAZOS • LICENSE NUMBER: ME41056 Profession MEDICAL DOCTOR License/Activity Status CLEAR/ACTIVE License Expiration Date 1/31/2012 Discipline on File NO Address of Record 5040 NW 7 STREET SUITE 700 MIAMI, FL 33126 UNITED STATES License Original Issue Date 10/27/1982 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. 1 .. ._ tL____'l J_1. _a_.-_ n /TT a .rnnTT ♦ rni "E INCORPORATED 1936 ATTESTS THAT VaX00 HAS MET THE REQUIREMENTS OF THIS OARD AND IS HEREBY DESIGNATED A DIPLOMATE !.ERTIFIED IN THE SUBSPECIALTY OF CARDIOVASCULAR DISE SE CHAIRMAN AMERICAN HOARD OF INTERNAL MEDICINE 41a, NUMBER 113810 4,d€€'� £ C ay�s' AN-EtECT AMERICAN Be • :. OF INTERNAL MEDICINE SUBSPECIALTY BOARD ON CARDIOVASCULAR DISEASE D67-ta-td 7 SECRETARY.TREASURER AMERICAN BOARD OF INTERNAL MEDICINE INCORPORATED 1936 ATTESTS THAT HAS MET THE REQUIREMENTS OF THIS BOARD A D IS HEREBY DESIGNATED A DIPLOMATE CERTIFIED IN THE SPECIALTY OF INTERNAL MEDICI E SEPTEMBER 16, 1987 7 .6 7 • .L__1 L__11 Ij• .L_Ji INCORPORATED 1936 I ESTS THAT Max Palms WHO IS A DIPLOMATE IN INTERNAL MEDI HAS MET THE REQUIREMENTS OF THIS BC) AND IS HEREBY OERi IHED TO HAVE SPECIAL QUALIFICATIONS IN CRITICAL CARE MEDICINE r r FOR THE PERIOD 1991 THROUGH,2001 1434atir..m4 aollakbr sPrnuout. blemarcE 9 wkip, MA- 11QQ1C1 CHAIRMAMIEcr maatiCAN MAIM or Daritsm. woa:3NE TEST COMMITTEE ON CRITICAL CARE MEDI 1),.....0.1s 6K•lc; Curriculum Vitae Max Pazos, M. D, P.A.. 747 Ponce De Leon, Suite 305 Coral Gables, Florida 33134 (305) 665-3129 Education Universidad Central del Este Dominican Republic Doctor of Medicine University of Miami rF Miami, Florida Bachelor of Science in Chemistry and Science Magna Cum Laude Miami Dade Community College Miami, Florida Associate in Arts Post Graduate Training Brown University Providence, Rhode island Cardiology Fellowship Massachusetts General/St. 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 1977 1975 1987-1988 1986-1987 1981-1983 1981.1983 Areas of Expertise Cardiac' Catheterization Holier Monitor reading, Swan -Ganz insertion and management. lntubation, Chest Tube insertion and management. Echodoppler, Exercise Stress testing, Nuclear Imaging, interpretation and report. Management of critical care medical / surgical patients. Languages English and Spanish Awards "Senior Resident of the Year Award" Brown University Providence, Rhode island Special Certifications American Board of internal Medicine American Board of Cardiovascular Diseases American Board of Critical care Medicine Soto Practice J i 1986 1987 1989 1991 1988-Present DEPARTMENT;OF -HEALTH • . 4:j 1 114 't-Na?-11 , kJ:17* ivi.c.tlik;i-N-L',.l.1.!-VML. 1-1-VT.'"AZZ:U.K.A"-NkA-.t. 15k17-"Es: ''-'-'-: ."---'''."-' - .i !;...,::::,:,k-.616Ei\itt,We6:::,.. ,.,•.':.:, ,t!Ntj'g'!:e_4z,l10. i.:•:. -', ------ .., .. . .... . ... ... .... f-71 . „ • STATEOFFLORIDA 0EgAloutiit.ORtitALTH. DIVISION OF MEDICAL QUALJTY ASSURANCE. . . ...„ „ • ..„ • • - 11t15/200.9. • , ..... • The MED8AL DOCTOR' namedeIowhas met aWrequirements the laws and rules JANUARY MANUEL SM LOVISK Arrit ftr.1e of Flor-ida: Expraton. state ...... 431 '••••-• LJCENSE NO. • •. 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LICENSE NO " :- . ... .CONTROL NO. 01/14/2009 ME 96844 274519 rhe MEDICAL DOCTOR lamed be owlia.§ met all requirements of • 101/vapd..:rufes of he state of Florida. ExOiratibii Date : ,....JANIUARY 31, 2011 kM16HkAGAIiWAL 929 EAST COMMERCIALI3Ly0 TE660 ••• • • • ..)ZT LApDp3DALE, FL 3308 -TEDSTATES • Cbaa:Crist GOVERNOR : • ,• . . . • . AnM. Viamonte Ro STATE SURGEON GENERAL DISPLAY IF REQUIRED BY LAW EXPIRATION DATE: JANUARY 31. 2041 2 co c\_!: (-4-) 7 • 4x <0 0 < < -4C -az M 0 ce OW 0-F- Z u_ • z- w < a.• 5 (F W 0 0 LICENSE NO. uJ w 0 p.1 FLORID . A',. A `cj 1 G 2 STATE OF DEPARTMENT OF HEALTH Q ,•ry DNISION o0wEDIGAL QUALITY ASSURANCE . .::DATE LICENSE NO. -0210512009 . ME 103650 Tfte : MEDICAL.DOCTOR named below has met all requirements of the.laws and rules afihe state of Florida. tipiration Date:' : JANUARY 31, 2011 RICHARD HENRYPARTIN LICEN' E SIGNATURE From: http://ww2.doh.state.fl.us/mgaservices/flhealth index.asp License Verification Data As Of 11/9/2010 GONZALO IGNACIO ARCENTALES LICENSE NUMBER: RN9258719 Profession REGISTERED NURSE License/Activity Status CLEAR/ACTIVE License Expiration Date 7/31/2012 License Original Issue Date 02/20/2007 Discipline on File Public Complaint NO NO Address of Record MERCY HOSPITAL 3663 SOUTH MIAMI AVENUE MIAMI, FL 33133 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. EXPERIENCE 2009 — Present 2007 — 2009 2007 1989-2007 1991 — 2007 1997 — 2004 GONZALO ARCENTALES, R.N., RCIS, M.B.A./H.A. 945 NW 197th Terrace Pembroke Pines, Florida 33029 (954) 430-0708 CeII (954) 665-1627 Nurse Manager, Employee Health Services Mercy Hospital, Miami, Florida Responsibilities include department operations, new and annual employee physicals, exposures, updating policies and procedures, reporting to Infection Control Committee, and spearheading the H1 N1 influenza response and vaccination program. Improved annual health review timely compliance from 83% to better than 95%.Improved record keeping and redesigned forms reporting methods to improve productivity. Nurse Manager, Arrhythmia Syncope Center Mercy Hospital, Miami, Florida Responsibilities included operations, finances, purchasing, program development and marketing of an Electrophysiology outpatient laboratory. The center provided diagnostic and interventional EPS, device implants (pacemaker, ICD, BiV ICDs, Loop Recorders), arrhythmia and syncope clinic as well as research. Worked as a team member with the Medical Director and VP of Business Development in the strategic development of product line to increase EP volume and revenue at the center and at the hospital. Increased procedure volume from 2007 to 2008 by 23% and clinic visit units of service by 22% with similar revenue growth. Nurse, Cardiac Catheterization Laboratory Tenet Florida Medical Center, Lauderdale Lakes, FL Perform all nursing duties of interventional cardiac cath lab. Attended Critical Care Course. Director, Cardiac Catheterization Laboratory Tenet Palmetto General Hospital, Hialeah, FL Cardiac Catheterization Laboratory: From inception, developed and implemented invasive Cardiovascular Laboratory. Hired, trained, and developed staff for all range of department duties. Responsible for budgeting, productivity management, performance improvement, JCAHO; business development and capital planning and implementation. Implemented Intra-Aortic Balloon Pump Program, Electrophysiology program. and device implanations (pacemaker, ICD, BiV ICDs, Loop Recorders). Developed and implemented all facets of Interventional Cardiology Program including Certificate of Need process responsibilities, selection and purchase of all major capital equipment, site design development, marketing and writing Policies and Procedures for new digital cath lab suites and eight bed recovery area. 2,000 procedures, 700 interventions estimated for first year of service. Expanded the Electrophysiology Program to perform interventions. Spearheaded the purchase and selection of equipment and supplies to perform peripheral vascular procedures. EKG and Echocardiography: Responsible for the leadership and operations of high volume EKG Department and Echocardiography Laboratory. Launched EKG digital management system in 1997. Enhanced Echocardiography Services and operations to increase throughput of outpatient volume. Acquired digital Echo Systems to enhance and expand this service and improve diagnostic/reporting capability. Sleep Disorders Center: Developed proposal including pro -forma analysis and payor mix analysis for new hospital product line. Obtained capital funding and implemented all facets of program. Set up and sustained a fully operational 2-bed department which, because of its success, expanded to 4 beds in 2001 then 6 beds in 2002. Gonzalo Arcentales Page 2 2000 — 2005 Neurophysiology Department: Responsible for leadership, development and operations. Worked with staff to increase throughput and productivity by 20%. 1996 —1997 Respiratory Department: Responsible for leadership, development and operations included Pulmonary Function and Arterial Blood Gas Laboratories. Other Roles Team Leader — Business Plan Development for Cardiology Product Line Facilitator — Performance Improvement Team Member — Performance Improvement Council Chairman — Quality Improvement Council Coordinator - Quality Management Resource/Measurement 1988-1989 Director, Cardiac Catheterization Laboratory South Miami Hospital, Miami, FL Responsible for administrative duties of Cath Lab (1300 procedures per year including 500 interventional procedures). Coronary angioplasty, valvuloplasty and Excimer LASER assisted angioplasty (first in Florida). Implemented inventory control procedures. Redesigned flow process of patient results reporting. 1986-1988 Director, Cardiovascular Laboratory St. Francis Hospital, Miami Beach, FL Responsible for directing Interventional Cardiac Catheterization Laboratory (900 procedures per year), Echocardiography Lab, and Stress Test Lab. Implemented "Open Lab" and streamlined procedures. Developed spreadsheet software programs for reporting patient data, and film quality control. 1983-1986 Cardiovascular Technician Mount Sinai Medical Center, Miami Beach, FL Cardiac Cath Lab: Performed Cath Lab duties, including PTCA and electrophysiological studies. Generated departmental revenue, expense and volume reports for Lab Director. Intensive Care Unit and Arterial Blood Gas Lab Tech: Set up and assisted with insertion of invasive peripheral lines. Performed blood gas draws and analysis. 1982-1983 Tumor Registrar Mount Sinai Medical Center, Miami Beach, FL Abstracted medical records of patients diagnosed with cancer. EDUCATION 2005-2006 Miami Dade College, Miami, FL A.S.N. Degree Nursing Program 1989-1991 University of Miami, Graduate School of Business Administration Coral Gables, FL Master of Business Administration - Specialization in Health Administration 1978-1983 Columbia University, Columbia College New York, NY Bachelor of Arts: Biology Honors: New York State Regents Scholarship Recipient CERTIFICATION Registered Nurse (Florida RN 9258719 exp 7/31/2012) Registered Cardiovascular Invasive Specialist (RCIS) 00011950 expires 12/31/2009 Other Current BLS (exp 10/2011) Current ACLS (exp 5/2012) SKILLS Spreadsheets, Word -Processing, PowerPoint, Database. Bicultural and bilingual (Spanish). AC STATE OF FLORIDA DEPARTMENT. OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTROL NO. 03/07/2009 RN 2562922 1072347 LEGISTERED NURSE j.i.belowhas met all requirements of the laws and rules ofthe state of Florida. Expiration Date APRIL 30, 2Q11'P NANCY.. LEE AROCHO., 7631 CORAL BOULEVARD MIRAMAR, FL 33023-5980., Charlie Grist • GOVERNOR Ana. M. Viamonte Ros, M.D., M P.H.:: STATE SURGEON GENERAL DISPLAY IF,'REQUIRED BYLAW 0 z 0 CC z 0 0 LICENSE NO. NANCY LEE AROCHO V Z. 1 V r tih Jv 71077V17 Human 1tebourceb Iealthcare Practitioner License Display License Verification Data As Of 7/27/2010 MILAGROS LOSA LICENSE NUMBER: R012752512 Page 1 of 1 Primer Friendly Version IE Oenerel Inrormation Profession REG[SfERED NURSE License/Activity Status C! PAR/ACfIVF License Expinition Date License Original Issue Date 4/30/2012 07/07/1993 Public Compie IntO NO NO Discipline on Pile Address of Record MERCY HOSPITAL 3663 SOUTH MIAMI AVENUE MIAMI, FL 33133 The information on this page Is a secure, primary source For license verification provided by Tne Hoene Department or Health, Division 9F Medical Quality Assurance. This websitc is maintained by Division staff and is updated Immediately upon o change to our licensing and enforccrnont database_ http://ww2.doh.state.fl. us/irrn00pracs/PRASTNDLASP?LicId=13 8765&ProtNBR=1.701 7/27/2010 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 Intensivists, providing services solely in said capacity and not as physicians engaged in private practice, as independent contractors to the Hospital. 11 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. 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 967-01 1 (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 for 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 you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. 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 967-01 1 (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 967-01 1 (Rev. 7/04) -3- 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 967-01 1 (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 byyour 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. •) j 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 33133 Privacy Complaint: Privacy Officer, Corporate Compliance Department, Mercy Hospital, 3663 South Miami Avenue, Miami, FL 33133 Form 967-01 1 (Rev. 7/04) -5- OUtpvtlent 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 patient's 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 will 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 Initials If 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 1 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 Form 967-010MOC Rev. 01/07 ❑ Yes ❑ No 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 (substanceabuse records and/or HIV test results) will 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. Whi 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: Name of Person DOB, Tel # or Other Identifier Initial Add -on or Deletion Date To replace a person's name, if deleted above: DOB, Tel # or Initial Add on Name of Person Other Identifier or Deletion Date tit�ate of Admission /Treat 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. * HIV test results: I authorize and hereby consent that the verbal communications may contain HIV test results. Yes ❑ No (initials) (initials) PATIENT SIGNATURE Date: Patient name (print) Patient Signature/Health Care Surrogate / Proxy Print name if health care surrogate or proxy Relationship to patient Witness signature Print name if witness thorization to Release and Communicate Protected { alth Information (PHI) to Family Members and Friends fCY owital I1I i i 0 Form # 967-010 Page 2 of2_..._........ Current: 06/30/09 ACCT# MR# DOB FC 1 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. j signing this form, I consent to the hospital's use and disclosure of protected health information about myself 1 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 nt 0 Patient refused to sign Reason: ❑ 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. 'formation about you generally will be included in our Facility Directory to enable family and concerned 'Adividuals to inquire about your location and condition on the nursing unit only. We will disclose your location ar 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. El I want to be included in the Hospital Facility Directory. I understand my name, location, and general conditic 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 f you do not want to participate in the Facility Directory, please indicate below what you wish to be excluded: ❑ Your name and location ❑ General condition 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. 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 wil not be made available to clergy and Pastoral Care. Patient's initials horization to Release and Communicate Protected alth Information (PHI) to Family Members and Friends Hospital Y W A u V Form if 967-010 Page 1 of 2 Current: 06/30/09 ACCT# MR# DOB FC ret +' 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 Recibo de La Notificacion de Privacidad He recibido una copia de la Notificacion de Privacidad del Mercy Hospital, version vigente firmar este documento, autorizo al Hospital a utilizar y a divulgar informacion confidential fines de tratamiento, pagos o servicios medicos, asi como para los propesitos que se han de Privacidad. Tengo el derecho a revocar esta autorizacion por escrito, excepto donde entidades nombradas en esta Notificacion de Privacidad hayan divulgado informacion Para Uso Del Hospital Solamente If acknowledgment of receipt of the Joint Notice of Privacy Practicos is not obtained from representative, picase explain your efforts to obtain their acknowledgment and the reason IIPatient refused to sign ❑ Unable to obtain signature Reason: del Mercy Hospital desde el 14 de abril del 2003. Al medica sobre mi persona con estipulado en esta Notificacion el Mercy Hospital o las otras utilizando mi consentimiento previa. lniciales del Paciente the patient or the patient's you couid not obtain it: ❑ Other Mercy Hospital Representative Signature D Date Instrucciones Para El Directorio Del Hospital Este formulario autoriza o restringe la divulgaci6n de su nombre o localizacion en el Directorio del Mercy Hospital. lncluimos 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 religiosa que usted ha indicado durante, la evaluation inicial 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 continuacion su preferencia. ❑ Deseo que me incluyan en el Directorio del Hospital. Entiendo que mi nombre, localizacion y condicion general estaren 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 continuacion que usted desea ser exclufdo: ❑ Nombre y localizacion. Entiendo que al negarme a proveer esta informacion, los visitantes no se podran poner en contacto conmiqo a menos que yo mismo les haya dado mi nombre, numero de habitation y/o telefono. Nota: Los visitantes incluyen miembros de la familia, Ilamadas fuera del hospital y entregas de floristerfas. ❑ 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 religiosa Entiendo que al negarme a divulgar esta informacion, mi afiliacion religiose no estara disponible para miembros del clero o para el sacerdote del hospital. Inlciales 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 mi informacion de salud se divulgue con el proposito de comunicar resultados, hallazgos, y decisiones sobre mi salud a mi familia o a otras personas responsables 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 de la prueba del virus VIH) no seran divulgados sin mi previa autorizacion. Form 967-009MOC_Rev. _01/07 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 designado e indicado a ^'ntinuacion. Al escoger los individuos favor de tomar en consideracion. Una persona debe ser su representante sobre el cuidado de su salud, se tiene un representante sobs 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 ariadan o se eliminen despues de las solicitud inicial. ❑ No deseO_ designar.a ninguna_persona. Favor escribir en (etre de molde la siguiente informacion: Nombre de Ia persona Fecha de nacimiento, edad, numero de telefono u otro identificante iniciales para anadir o eliminar 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 la persona u otro identificante personas Fecha • Fecha de admision/tratamiento: • Esta Autorizacion expirara cuando el paciente sea dada de alta. La Autorizacion para la continuidad del cuid ` .i else of ados cone to ae dm s oicnios Sociales se extiende despues que el paciente es dado de alta pars asuntc Autorizacion pars comunicar informacion sensitive del paciente Consultas o notas psicoterapeuticas/psiquiatricas: Autorizo y doy mi consentimiento para que las comunicaciones verbales incluyan consultas o notas psicoterapeuticas o psiquiatricas. ❑ Si ❑ No • Archivos de abuso de sustancias: Autorizo y day mi consentimiento para que las comunicaciones verbales sustancias. ❑ Si ❑ No informacion acerca de (firme sus iniciales) incluyan registros acerca del abuso (firme sus iniciales) • Resultados del examen del virus VIH: Autorizo y doy mi consentimiento para que las comunicaciones verbales incluyan virus VIH. ❑ Si ❑ No (firme sus iniciales) FIRMA DEL PACIENTE Nombre del paciente (en tetra de molde) Firma del paciente/Representante del paciente sobre el cuidado de su salud Firma del testiao resultados de Ia prueba del Fecha Escriba en tetra de molde el nombre del representante del paciente sobre el cuidado de su salud Parentezco con el paciente Nombre del testi `orizacion Para Divulgar y Comunicar Informacion Protegida Salud (PHI) Con Miembros De La Familia y Amistades r•fik-Rair HosAlba N i i 111 IH i i u 111 M ui Form # 967-010S Pageof2 Current: 06/30/09 ACCT# MR# o (en Ietra de molde DOB FC Reconocimiento del Paciente del Recibo de La Notificacion de Privacidad del Mercy Hospital He recibido una copia del la Notificacion de Privacidad del Mercy Hospital, version vigente desde el 14 de abril 2003. Al firmar este documento, autorizo al Hospital a utilizer y a divulgar informacion confidential medica sob: mi persona con fines de tratamiento, pagos o servicios medicos, asi como para los propositos que se han tipulado en esta Notificacion de Privacidad. Tengo el derecho a revocar esta autorizacion por escrito, excepl .onde el Mercy.Hospital o las. otras entidades nombradas en esta Notificacion de Privacidad hayan divulgado informacion utilizando mi consentimiento previo. Para Uso Del Hospital Solamente Iniciales del pacier 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- ni obtain it: ❑ Patient refused to sign ❑ Unable to obtain signature ❑ Other Reason: Mercy Hospital Representative Signature Date Instrucciones Para El Directoria Del Hospital Este formulario autoriza o restringe la divulgacion de su nombre o localizacion en el Directorio del Mercy Hospit Incluimos su informacion general en nuestro directorio para que su familia y las personas interesadas en su salf 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 Ia afiliacion religiose que usted ha indicado durante, la evaluation initial que se efectuo en Ia unidad despues de su admision. Sin embargo, uste< puede restringirla informacion que se incluye en el directorio, y a quien se le divulge Ia misma, al indicar a continuation su preferencia. ❑ Deseo que me incluyan en el Directorio del Hospital. Entiendo que mi nombre, localizacion y condicion gene estaran disponibles para mis amistades, parientes y personas que Ilamen al hospital. 1.% Si no desea ser incluido en el Directoria 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 conmigo a menos que yo mismo les haya dado mi nombre, numero de habitation y/o telefono. Nota: Los visitantes incluyen miembros de Ia familia, Ilamadas fuera del hospital y entregas de floristerias. El Condition general Iniciales del pacie Entiendo que al negarme a divulger esta informacion, mis amistades y mi familia no podran obtener respuestas acerca de mi condicion general. ❑ Afiliacion religiose Entiendo que al negarme a divulger esta informacion, mi afiliacion religiose no estara disponible para miembros del clero o para el sacerdote del hospital lniciales 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 responsables por mi cuidado o designados por mi. Entiend, 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. (` 4 %itorizacion Para Divulger y Comunicar Information `. . rotegida De Salud (PHI) Con Miembros De La Familia y Amistades tqMERCY'i Form # 967-010S n hill V I Page-1 of-2- Current: 06/30/09 ACCT# MR# DOB FC Client List City of Miami Administrative Assistant II City of Miami Employee Relations Department 444 South West 2°d Avenue Seventh Floor Miami, Florida 33130 Tel: 305.416.2101 Reveca Valiente-Ortiz, Personnel Services Coordinator City of Miami Employee Relations Department 444 South West 2°d Avenue Seventh Floor Miami, Florida 33130 Tel: 305.416.2113 Fax: 305.416.2115 Rvaliente-Ortiz@miamigov.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 mpokrywka@eheintl.com Archdiocese of Miami 9401 Biscayne Boulevard Miami Shores, Florida 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. Proposers 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 rooms 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. rTh 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: 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: $ %S"•-5--c) Line: 1.2 Number of Units: 400 Total: $ Description: Additional/Optional Exams: Speculum and Bi-Manual Exam including Pap Smear Category: 94874-50 Unit of Measure: Each vo Unit Price: $ k s© Number of Units: 50 Total: $ 5).713 +' Line: 1.3 Description: Additional/Optional Exams: Mammogram Category: 94874-50 Unit of Measure: Each Unit Price: $ / 75 Line: 1.4 ad Number of Units: 50 Total: $ Description: Additional/Optional Exams: Comprehensive Hearing Test Category: 94874-50 Unit of Measure: Each Unit Price: $ 3� Number of Units: 20 ov Total: $ - Page 5 of 54 Unit Price: $ Line: 1.8 Line: 1.5 Description: Additional/Optional Exams: Echocardiogram Category: 94874-50 Unit of Measure: Each Unit Price: $ 395" Number of Units: 200 Line: 1.6 Description: Additional/Optional Exams: Thallium Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.7 o--s� Total: $ 79> Dc...)o met Number of Units: 50 Total: $ 5 5Q Description: Additional/Optional Exams: Exercise Muga Stress Test Category:94$74-50 Unit of Measure: Each � 3s Number of Units: 10 Total: $ 3 00 Description: Additional/Optional Exams: Hepatitis A and B Screening Category: 94874-50 Unit of Measure: Each Unit Price: $ Oa Number of Units: 200 Total: $ 6,1 SGav Page 6 of 54 Line: 1.9 Description: Additional/Optional Exams: Tetanus Toxoid Immunization Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.10 Numhcr of Units: 50 Description: Additional/Optional Exams: Tetanus Booster Category: 94874-50 Unit of Measure: Each Unit Price: $ Total: $ Number of Units: 75 Total: $ 02 j 7o Line: 1.11 Description: Additional/Optional Exams: Pulmonary Function Test - Flow Volume Loop Category: 94874-50 Unit of Measure: Each Unit Price: $ :;)d Line: 1.12 Number of Units: 50 Total: $ 3 i D-2°YJ Description: Additional/Optional Exams: Pulmonary Function Test - Post Bronchodilatory Study Category: 94874-50 Unit of Measure: Each Unit Price: $ 7 Line: 1.13 Number of Units: 50 Total: $ 3/tea-6 Description: Additional/Optional Exams: Radiological Evaluation Page 7 of 54 Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.14 Number of Units: 200 VT) Total: $ /5 ovZ) Description: Additional/Optional Exams: Flexible Sigmoidoscopy Category: 94874-50 Unit of Measure: Each Unit Price: $ 375- Line: 1.15 Number of Units: 10 Total: $ 3 , 75Z) GJ Description: Additional/Optional Exams: Colonoscopy Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.16 Number of Units: 10 Total: $ c+2f Description: Additional/Optional Exams: RPR Category: 94874-50 Unit of Measure: Each Unit Price: $ 3-0 Line: 1.17 Number of Units: 1 Total: $ /e • a-6 Description: Additional/Optional Exams: 24 Hour Hotter Monitor Category: 94874-50 Unit of Measure: Each Page 8 of 54 2�7 !• Unit Price: $ • 3`/5 Line: 1.18 Number of Units: 15 Total: $ S ' 907 `J Description: Additional/Optional Exams: Mantoux Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 1.19 Number of Units: 550 Total: $ � 015-0 Description: Additional/Optional Exams: Flu Shot Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 700 Total: $ a I/, s—v v Line: 1.20 Description: Additional/Optional Exams: Hazardous Material Team, Dive Team, TRT Physical Category: 94874-50 Unit of Measure: Each Unit Price: $ phi bD Line: 1.21 Number of Units: 170 Total: $ ' 5 j UDC) Description: Additional/Optional Exams: Bilirubin Direct and Toral Category: 94874-50 Unit of Measure: Each Unit Price: $ / U ' (I"U Number of Units: 170 Total: $ / 74-0 Page 9 of 54 Line: 1.22 Description: Additional/Optional Exams: Cholinesterase Category: 94874-50 Unit of Measure: Each Unit Price: $ w7 . S---o Number of Units: 170 Total: $ ca-5- " Line: 1.23 Description: Additional/Optional Exams: Heavy Metal Screening Quantitative for Pb (Lead), As (Arsenic), Fig (Mercury) Category: 94874-50 Unit of Measure: Each UnitPrice: $ OC Line: 1.24 Number of Units: 170 Total: $ a'D Description: Additional/Optional Exams: Tonometry Category: 94874-50 Unit of Measure: Each v1. Unit Price: $ /6 . Sb Number of Units: 170 Total: $ // 71:5-- Line: 1.25 Description: Hepatitis A Immunizations - First Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ (a� Number of Units: 50 Total: $ 3i t/-tr-C.) Page 10 of 54 Linc: 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 Description: Hepatitis B Immunizations - First Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ 1GC) Number of Units: 50 Total: $ .. 0 0-0 Line: 1.28 Description: Hepatitis B Immunizations - Second Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 50 Line: 1.29 Description: Hepatitis B Immunizations - Third Injection In accordance with specifications ot7 Total: $ Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 50 Total: $ Line: 1.30 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: $ /o 9Z Line: 1.31 Number of Units: 50 rN! Total: $ 5 mod - Description: Hepatitis A and B Combined (TWINRIX) - Second Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /d Number of Units: 50 Total: $ Line: 1.32 Description: Hepatitis A and B Combined (TWINRIX) - Third Injection In accordance with specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /6/ Number of Units: 50 Total: $ S� Line: 1.33 Description: Additional/Optional Exams: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Ti Line: 2 Number of Units: 400 Total: $ //6>D/ 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 ti Unit Price: $ f Line: 2.2 Number of Units: 1,100 Total: $ -c') 42- Description: Pulmonary Function Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 50 Total: $ 3 , 'o ) Line: 2.3 Description: Electrocardiogram (EKG) Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 1,100 Total: Line: 2.4 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-cro Page 13 of 54 Description: Additional/Optional Earns: Radiological Evaluation Catenary: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.6 Number of Units: 800 Total: $ 6'0/ Description: Additional/Optional Exams: Cardiovascular Stress Test Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 100 e-d 4)4 Total: $ c:77c3i 06+16 Line: 2.7 Description: AdditionaUOptional Exams: Echocardiogram Category: 94874-50 Unit of Measure: Each Unit Price: $ 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 ci-C) --C_) Tota:$ Description: Additional/Optional Exams: Exercise Muga Stress Test Page 14 of 54 Category: 94874-50 Unit of Measure: Each Unit Price: $ 1"% Line: 2.10 Number of Units: 1 Total: $ 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 Total: $ 'v Description: Additional/Optional Exams: Pap Smear Category: 94874-50 Unit of Measure: Each Unit Price: $ 3� Line: 2.12 Number of Units: 10 Total: $ ic Description: Additional/Optional Exams: Mammogram Category: 94874-50 Unit of Measure: Each Unit Price: $ /7-S Line: 2.13 o-D Number of Units: 50 Total: $ 716 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: $ Number of Units: 600 Line: 2.15 Total: $ 9/ •/ crT� Description: Additional/Optional Exams: Comprehensive Hearing Test Category: 94874-50 Unit of Measure: Each c-0 Unit Price: $ � �� Number of Units: 10 Total: $ t3 Line: 2.16 Description: Additional/Optional Exams: 24 Hour Holter Monitor Category: 94874-50 Unit of Measure: Each Unit Price: $ �! Line: 2.17 Number of Units: 50 Description: Additional/Optional Exams: HBSAB Titer Category: 94874-50 Unit of Measure: Eae Total: $ / 7 r 760 Unit Price: $ / Number of Units: 1 Total: $ /5 Page 16 of 54 Line: 2.18 Description: Additional/Optional Exams: Flexible sigmoidoscopy Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.19 Number of Units: 1 Total: $ Description: Additional/Optional Exams: Tetanus Booster Category: 94874-50 Unit of Measure: Each Unit Price: $� Line: 2.20 41-41 Number of Units: 1.50 Total: $ 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: $ 3 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: $ Number of Units: 1 Line: 2.23 Description: Additional/Optional Exams: Tonometry Category: 94874-50 Unit of Measure: Each Total: $ 4 Unit Price: $ /6 • 6-7) Number of Units: 1 Total: $ Line: 2.24 Description: Additional/Optional Exams: RPR Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.25 Number of Units: 1 Total: $ 1 3 Description: Additional/Optional Exams: Blood Type Category: 94874-50 Unit of Measure: Each Unit Price: $ �d Line: 2.26 Number of Units: 1 Description: Hepatitis A Immunizations - First Injection Total: $ -3Q Page 18 of 54 In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.27 b Number of Units: 75 Description: Hepatitis A Immunizations -Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.28 Number of Units: 75 tre Total: $ � o--t Total: $ 5 / Description: Hepatitis B Immunizations - First Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.29 Number of Units: 75 Description: Hepatitis B Immunizations - Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.30 Total: $ 0 Number of Units: 75 Total: $ CL/ Description: Hepatitis B Immunizations - Third Injection In accordance with Specifications Category: 94874-50 Page 19. of 54 Unit of Measure: Each Unit Price: $ rb G Line: 2.31 0-0 Number of Units: 75 Total: $ Description: Hepatitis B Immunizations - Third Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Line: 2.32 Number of Units: 75 Total: $'� Description: Hepatitis A and B Combined (TWINRIX) - First Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ /C) fL Line: 2.33 Number of Units: 75 Total: $ % i ° D Description: Hepatitis A and B Combined (TWINRIX) - Second Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ `v Line: 2.34 Number of Units: 75 Total: $ 7i Description: Hepatitis A and B Combined (TWINRIX) - Third Injection In accordance with Specifications Category: 94874-50 Unit of Measure: Each Unit Price: $ Number of Units: 75 Total: $ Page 20 of 54 Trade Secrets Execution to Public Records Disclosures: There are no Trade Secrets contained in this proposal. December 21, 2010 Kenneth Robertson • Purchasing Director/Chief Procurement Officer 3.500 Pan American Drive Miami, FL 33133- SENT VIA EMAIL RE: Response to RFP:243.229,1 Annual Physical:Examination:Services For First Responders Dear Mr. Robertson, Please find .attached to this email the requested .documentation forthe above mentioned proposal. Please note there has been a :personnel change in the credentialing section. .Due to personnel changes at Mercy Outpatient Center, Opal T. Pitter, R.N., has replaced .Nancy Arocha, R.N. In regards to Section 4, sub -section 4-C, the required documentation has been submitted via this email. Sincerely, r � Reuben J. Camp, III,...MSN, RN Senior Director Cc: Yusbel Gonzalez: ygonzaiez@miamigov.com F' erc SC {tat ' A member of Catholic Health ?>t ' Sponsored by the 9?:eof St. J -ph of SL. Aug,.Stir 364.. South ('v'iarn; ue, Suite 250, r'd-.d( i, for da 3,_:_ ":.'s05_860.470G 1 305.285:2654 h KC'ENNE T H ROB RTSON Chief Procurement' Officer December 7, 2010 Mr. Reuben J. Camp III, MSN, RN Mercy Miedical Development d/b/a Mercy Ou a:tie r enter 3641 South Miami .Avenue Miami, FL 33133-4205 -SENT VIA EMAIL CARLOS A. MIGOYA City Manager RE: Response to UP 243229 Annual Physical Examination Services for First Responders Dear Mr. Camp, The City of Miami is in the process of evaluating your proposal response to RFP 243229 for Annual Physical Examination Services for First Responders. In order to assist us in the evaluation process, we need additional Information and documentation regarding your response. Line: Ile in the lines section of the RFP solicitation required Prospective Proposers to submit a unit price for the tollowina service: "Additional/Optional E;:ams: Stool Hernates`ffor Oc :ult Mood". Your proposal response, however, state: in the Unit Price and Total fields the following information: "NC". In an effort to complete the evaluation of your proposal response, plc se indicate below what is mean: by "NC": Additionally, pursuant to Section 4, Submission Requirements, sub -section 4c), of the RFP solicitation document. the following requirement is stated: Submit.a.copy(s) of credentiais.and.State of Florida license for:the-following individuals: -Physicians performing physical examinations (Submit -copies of:Board Certification in internal Medicine or Family Practice) -Cardiologists -Radiologists -Audioiogist -Medical Professional Staff: - Registered nurse and/or licensed medical professional providing '-iepatitis A and 8 immunization. Certified medical personnel aominisiering Hepatitis A and F tests. Although -your -proposal-response-included-State-of-Florida-/icense-tor-the-Radiologists, it tail d to ncfud� fh "credentials" for these -individuals.--The--same is applicable -f'or-Registered -Nurses- Nancy --- Arocho and Milagros Losa. In an effort to complete the evaluation of your proposal response, please provide the .credentials (i.e. qualiiications, education diplomas in the Radiology field, and/or resumes) for the Radiologists included in your proposal and the two Registered Nurses stated above, Copies of the licenses submitted with your proposal have been attached to this letter for your reference. Furthermore, pursuant to Section 3,1, Soecifications/Scone of Work, under both Group 1 and 2, subsection Ii. A. 9), of the RFP solicitation document, the following requirement is stated: Mr. Reuben J. Camp III, MSN, RN December 7. 2010 Page 2 "Ali physical examinations, tests and related medical procedures shall be conducted in licensed facility operated by the Successful Proposer, or at such facility subsequentiy agreed to by the City and the provider" Although under Section 5 of your proposal response you indicated that the "Radiological Department" 'at __Mercy's_ Center- for Health Promotion '';is e,gcrioped with (5)_x-ray-rooms (-::r ..it -was 'noted that you included copies of licenses for Radiologist who work with Mercy Medical Development and South Florida Medical imaging, For clarification purposes, please indicate in the space provided below what is the role of South Florida Medical imaging in providing Radiology services under Mercy Medical Development's proposal for RFP 243229. tom; r'i- :,20 r'fl'`): ! // c.t..i_; —7 :7 ;7 r�J r..,� . �. -. ' 7 1 ...�-- f a✓`... �/ c_ f__ ,t'? y / f Moreover, while evaluating your proposal response, we .encountered 2discrepancy .between the unit price :and extended price for Line 2.1 and 2:6. When ..ever :said .discrepancy occurs, :Section 1.61(E.), PREPARATION ION OF RESPONSES (HARDCOPY -FORMAT), states: �...,% In case .o; a discrepancy between the .snit price and extended price, the unit price will be presumed correct" Therefore, please review the corrected proposal line item .shown -below .and confirm if the Unit Price .Is correct and if -you agree with the corrected extended prices for line item 2.1. and 2.6. Line. 2:1 :Description: Basic Physical (including lab wort;, visual exam, and Audiological Exam) Unit of Measure: -Each Unit Price: $140.50 Number of Units: 1,100 Extended Price (as shown in -the bid response): S56.200.20 Corrected Extended Price:.S1.54.550.00 ['Y s, Unit Price is correct and I agree with the Corrected Extended Price. [ j Nc, Unit Price is not correct and I hereby retract my bid for this rem. Line: 2.6 Descripttion:-Additional/O.ptional-Exams.:..Cardiouasc.ular_S.tcvss Test Unit.of Nteasure...=ace_ - Unit Price: 5400 Number of Units: 00 Extended Price (as shown in the bid response): 520.000.00 Corrected Extended Price: $40.000 &?' F [v.-Yes, Unit Price is correct and I agree with the Corrected Extended Price. [ j No, Unit Price is not correct and I hereby retract my bid for this item. Mr. Reuben J. Camp III, fl1SN, R f! December 7, 2010 Page 3 Lastly, oursuani to Section 4 Addenda_ of the ' solicitation dooumen , the following rvquneem_nt !' stated: "it is the hrdders/proposer's responsibilhy to ensure receipt of al; Addenda Addenda are available at the Cit'/'s wecsiie a(: http://vww.ci_miami.fl.uslnrocurement' Within your response, however, there was no indication that you aci;nowiedaed receipt of Addendum No. 1. At this time, please sign and date on the following page to acknowledge receipt of Addendum Ido. 1 and to certify the responses made, to the questions stated it this letter.=ailure to acknowledge receipt of addenda, may cause for the City to reject your response, as. stipulated in Section 1.34, '_valuation of Resnonses. • Pri.,nt Name Title Signature Jaye-. A response to this letter, along with ail documentation requested herein. must be submitted to the attention of Yusbel Gonzalez via email: vaon_aiezic7miamiaov.com or fax: 3D5-400-5104, by no later than December 2 i. •2[ .0. at: :00 P.m. Failure to respond by the sfipuiated date.andi time may -deem your propose! non -responsive. Thank you for your cooperation. Sincerely, Kenneth Robertson Purchasingg. Director/Chief Procurement Officer KR:yc Cc: RFP file Attachments: State of Florida licenses for Radiologists and Registered Nurses (missing credentlals). Addendum No. 1 published November 4, 201.0. 1 CURRICULUM: VITAE CHARLES FRANKLIN TATE III, M.D., F.A.C.R. DATE OF BIRTH: April 26, 1947 HOME ADDRESS: • 1090 SW 15`1' Street Boca Raton, Florida 33486 (561) 417-6152 PROFESSIONAL STATUS: South Florida Medical Imaging, P.A. (Independent Contractor) Fort Lauderdale, Florida Private Practice in Diagnostic Radiology, Medical imaging and Interventional Radiology Holy Cross Hospital Fort Lauderdale, Florida 2004-present Mercy Hospital Miami, Florida 2005-present North Ridge Medical Center Fort Lauderdale, Florida 2004-2006 .Lnterventional Radiology Associates of Fort Lauderdale, P.A. Vascular Interventional Section Department of Radiology Holy Cross Hospital Fort Lauderdale, Florida 2002-present Radiologists of North Foie Lauderdale, P.A. Department of Radiology Holy Cross Hospital Fort Lauderdale, Florida 1982-2002 LICENSE: State of Florida, 1974, ME 0022357 BOARD CERTIFICATION: EDUCATION: National Board of Medical Examiners, 1974 American Board of Radiology, Diagnostic Radiology, 1982 American Board of Radiology, Certificate of Added Qualifications in Vascular and Interventional Radiology, 2000-2010 University of Florida, A.A. 1967 University of Miami (Florida), B.S. 1969 University of Miami School of Medicine, M.D. l 973 POST GRADUATE: internship -Straight Surgery -University of Miami/ Jackson Memorial Hospital, Miami, FL 1973-1.974 AWARDS/HONORS: COLLEGE: MEDICAL SCHOOL: POST GRADUATE: PRIVATE PRACTICE: Active Duty, United States Navy, 1974-1977 Designated Naval Fli<,ht Surgeon Resident -Straight Surgery -University of Miami/ Jackson Memorial Hospital, Miami, FL 1.977-1 978 Radiology Residency -University of Miami/ Jackson Memorial Hospital, Miami, FL 1978-1981 Fellowship Interventional Radiology, CT and Ultrasound University of Nliami/Jackson Memorial Hospital, Miami, FL 1981-1982 Alpha Epsilon Delta (Premedical National Honor Society) 1967 President, Freshman Class Vice President, Sophomore Class Chancellor of Honor Court Omicron Delta Kappa (National Leadership Honor Society) Iron AITOW (University of Miami Honor Society) Sikoesky Lifesaving Award (Air -Sea Rescue) Iceland, 1975-1977 President, University of Miami Affiliated Housestaff Physicians' Association, 1980 Elected Fellow, American College of Radiology 9/20/94 Chair, Department of Radiology, Holy Cross Hospital 1993-1996 President of Medical Staff, Holy Cross Hospital, 1997 President, Caducean Society of Greater Fort Lauderdale, 1993 PROFESSIONAL AFFILIATES AND COMMITTEES: PRESENT IVOVIBER: American College of Radiology (ACR) Alternate Counselor, 1996-1997 Counselor, 1990-1996 Florida Radiological Society Secretary, 1996-1997 Treasurer, 1995-1996 Co -Chair Ad Hoc Cornniittee on Interventional Radiology, 1991-1992 Chair Program and Education, 1992-1993 Society of Interventional Radiology (SIR) Standards of Practice Committee, 1.989-1992 Annual Meeting Committee, 1985 American Heart Association Council on Cardiovascular Radiology South Florida Society of Interventional Radiology PAST MEMBER: PRESENTATIONS/ PUBLICATIONS: RESEARCH: Vice President, 1993-1994 American .Medical Association (AIv1A) Florida Medical Association (FMA) Broward County Medical Association (BCMA) Chair Membership Conunittee, 1993-1994 Caducean Society Greater Fort .Lauderdale Dade County Medical Association (DCMA), 1979-1981 Executive Committee, 1979-1980 CME Committee, 1980 • Radiological Society of North America (RSNA) South Florida Radiological Society President, 1988 Tate, C.F. III, Intestinal Obstruction in a 55 Year Old Man With Previous Thoracic Surgery (Extrapleural Plombage) JAMA, Vol. 243, No. 10, pg 1077. "OUTPATIENT MYELOGR&PHY; A New Technique with Minimal Side Effects", presented RNSA, 1984, Washington, D.C. Tate, Charles F III, Wilkov; Lestrange, Outpatient Lumbar Myelography, RADIOLOGY 1985: 157: 391-393. Lestrange, Wilkov, Tate, C.F. III; Advantages of Ambulatory Metrizamide Myelography with Contrast CT Tomography, Orthopedics, 1986, Vol. 9, No. 1, 61-65. "NONSURGICAL TREATMENT OF PERIPHERAL VASCULAR DISEASE", PRESENTED April 15, 1989. Update 89. The Latest On Primar-v Care Medicine (CME Category 1, 16 hour course sponsored by Holy Cross Hospital, Ft. Lauderdale, FL "Managed Care in Florida", presented Florida Radiological Society Annual Meeting 7/12/97, Patin Harbor, FL The US StuDy for Evaluating EndovasculaR TreAtrnents of Lesions in the Superficial Femoral Artery and Proximal Popliteal By using the Protege EverfLex Nitinol STent SI'stem II (DURABILITY II), Protocol P-2424: Sponsor: ev3 Endovascular, Inc. GORE VIABAIIN iz Encloprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease (VIPER), Protocol \'TR 07-03 Sponsor: W.L. Gore & Associates, :Inc. 34 min Infrareual Bifurcated Stent, Protocol 07-001 HOBBIES: Sponsor: Endologix, lnc Prospective aneurysm Trial Fligh AnGle AORfix bifurcated Stem graft, Protocol 2005-01. Sponsor: Lombard Medical Technologies, Inc. Carotid Revascularization with ev3 Arterial Technology Evolution Post Approval Study (CREATE- PAS), Protocol P-261 1 Sponsor: ev3 Endovascular, Inc. Post Marketing Study Stenting and Angioplasty with Protection in Patients at IIigh-Risk for Endarterectomy (SAPPHIRE-WW), Protocol P06-3603 Sponsor: Cordis Corporation Gore Viabalnn Endoprosthesis Versus Bare Nitinol Stent in the Treatment of Long (> 8 cm) Superficial Femoral Artery Occlusive Disease (VIBRkN'T), Protocol SFA 05-03. Sponsor: W. L. Gore & Associates Emboshield and Xact Post Approval Carotid Stent Trial (EXACT), Protocol 640-0063-01. Sponsor: Abbott Vascular Carotid Artery Stenting with Emboli Protection Surveillance — Post Marketing Study (CASES-PMS), Protocol PO4-5204 Sponsor: Cordis Corporation Positive Impact of Endovascular Options for Treating Aneurysm Early (PIVOTAL) Study, Protocol VS-2005-01 Sponsor: Medtronic / The Cleveland Clinic Foundation Phase I Clinical Study of the Safety and Perfonnance of the Relay Thoracic Stent-Graft in Patients with Thoracic Aortic Pathologies, Protocol II'-0001-04. Sponsor: Bolton Medical Reading (American History) Hunting/Firearms Snow Skiing Jack Russell TelTiers October 2010 ?, CURRICULUM VITAE PERSONAL Name: CLAU-DIO M. SMUCLOVISICY, MI?, FSCCT Address: South Florida Medical Imaging, PA 2900 N. Military Trail Suite l01 Boca Raton, Florida 33431 Telephone: (561) 314-2500 Facsimile: (561) 314-2501 Email: drs(2uusfmicvi.com Website: www.sfimcvi.com Current Position: Director, South Florida Medical imaging Cardiovascular Institute, Boca Raton,'Florida HIGHER EDUCATION Medical School: Internship: 3. POSTDOCTORAL TRAINING Residency and Fellowship: University of Buenos Aires Medical School Buenos Aires, Argentina M..D. , December 1980 Associate Member, Division of Nuclear Medicine, Otamendi Hospital Buenos Aires, Argentina 1981 Associate Member, Division of Nuclear Medicine, Children's General Hospital, Buenos Aires, Argentina, 1981 Chief Resident and Assistant Instructor, -Dia iiostic'Ridiology,`Uiiive-sity of'Miati i / Jackson Memorial Hospital Miami, Florida, July 1985-June 1986 PREMEDICAL TRAINING 4. BOARD CERTIFICATION AND LICENSURES Residency - .Diagnostic Radiology, Department of Radiology, University of Miami / Jackson Memorial Hospital, Miami, Florida, July 1983-June 1986 Chief Resident and Assistant Instructor, Division of Nuclear Medicine, University of Miami / Jackson Memorial Hospital, Miami, Florida, July 1982-June 1983 Residency - Nuclear Medicine, Department of Radiology, University of Miami / Jackson Memorial Hospital, Miami, Florida, February 1982-June 1983 Chief Technologist, Division of Nuclear Medicine, Buenos Aires Children's General Hospital, Buenos Aires, Argentina, 1976-1980 Registered Technologist, Division of Nuclear Medicine, Buenos Aires Children's General Hospital Buenos Aires, Argentina, 1975-1980 Certifications:. Diplomate, American Board of Radiology, 1987 Diploinate, American Board of Nuclear Medicine, 1986 iplomate, Certification Board of Cardiovascular Computed Tomography, 2008 Fellow, Society of Cardiovascular Computed Tomography. 2010 State of Florida Medical Licensed DEA Licensed 5. . PROFESSIONAL EXPERIENCE Academic Anpointments: Hospital Appointments: Non -Academic Appointments Clinical Assistant Professor of Radiology, University of Miami School of Medicine, Miami, Florida 1986-1.998 Assistant Instructor of Radiology University of Miami; School of Medicine, Miami, Florida, 1982-1985 Instructor of Anatomy, Physiology, Clinical and Surgical Pathology, Diagnostic Radiology, Ultrasound, and Nuclear Medicine, School of Technology, Jackson Memorial Hospital, Miami, Florida 1.982-1985 Active Medical Staff Member of: Holy Cross Hospital, Ft. Lauderdale Holy Cross HealthPlex, Fort Lauderdale Mercy Hospital, Miami Director of Department of Nuclear Medicine, Magnetic Resonance hnaging and Ultrasound and Staff Radiologist, North Ridge Medical Center, Ft. Lauderdale, Florida. July 1989-2006 Attending Radiologist, Department of Radiology, University of Miami, School of Ivledicine_ April 1989-June 1989 Director Section of Nuclear Medicine and Staff Radiologist. Humana Hospital Bennett, Plantation, Florida, July 1986-March 1989 Director and Principal Instructor of a nationally recognized SCCT Endorsed Cardiac CTA Training. Teaching Certification and CME Level 1, 2 & 3 advanced cardiac CTA training. Chosen by Philips to establish the first training center in the US. Participants have included University Professors, Interventional Cardiologists, Clinical Cardiologists, interventional Radiologists, Diagnostic Radiologists and Nuclear Cardiologists. June 2005-Present National Panel Reviewer, American College of Radiology Accreditation of Nuclear Medicine Departments in academic and private centers. 2000-present 3 Areas of Expertise: National Panel Reviewer, American College of Radiology Computed Tomography Accreditation of academic and private centers. 2007-present AHCA: Panel of expert consultants for the State of Florida. 2002-Present. Advanced multislice CT angiography applications with emphasis on cardiac diseases, Magnetic Resonance Imaging, Computerized Tomography, Neuroradiology, Breast Imaging and intervention, Ultrasound: general and vascular, General Diagnostic Radiology, Myelography, Biopsies: US and CT guided. Musculoskeletal radiology, Nuclear Medicine: diagnostic and therapeutic, Advanced computer workstation applications. Level 3 Certified Cardiac CT: Society of Cardiovascular Computed Tomography (SCCT) 2007 Organizations: Association of University Radiologists (Chief Residents), 1985 American College of Radiology, 1983 The Radiological Society of North America, 1983 The South Florida Radiologicall Society, 1983 Florida Radiological Society, 1983 The Society of Nuclear Medicine, 1982 American ;Medical Association, 1982 Society of Cardiovascular Computed Tomography (SCCT): Founding Member 2005 North American Society for Cardiac 1995 Military: Captain, USAFR 1984-1992 Honorable Discharge aging (NASCI) 4 (. SCIENTIFIC PRESENTATION AT NATIONAL AND INTERNATIONAL MEETINGS: AWARDS: Improving the Technique of Scintigraphic Cystog2-aphy. 29th Annual Meeting of the Society of Nuclear Medicine, Miami, Florida, June 1982 Scrotal Scintigraphy for the Evaluation of Testicular and Epididymal Pathology. 30th. Annual Meeting of the Society of Nuclear Medicine; St. Louis, Missouri, .tune 1983 Radioimununoimaging of Experimental Synigenic Prostatic Adenocarcinoma in Rats. 30th Annual Meeting of the Society of Nuclear Medicine, St. Louis, Missouri, June 1983 Role of Scintigraphy, Sonography and Fine Needle Aspiration Cytology in the Diagnosis and Management of Thyroid Masses. Annual Meeting of the Southeastern Chapter of the Society of Nuclear Medicine, Kissimmee, Florida, October 1983 Head Investigator for various scientific studies in the evaluation of peptides and monoclonal imaging: colon, breast, lung cancer and melanoma. Contributed to FDA approval of the radionuclides. 1991-1995 Selected Doctor of the Year, North Ridge Medical Center, Ft. Lauderdale, Florida. 2002 Lectures extensively nationally and abroad on subjects related to Radiology and Nuclear Medicine. Sfalcianakis GN, Smuclovisky CM, et al: Improving the Technique of Nuclear Cystography. The Journal of Urology, Volume 131, p. 1061, June 1984 Smuclovisky C, Baum S, Dhir M, Arora UK, McInnis P. Evaluation of Patients Post Coronary Bypass with Cardiac CT Angiography South Florida Medical Imaging, Boca Raton, Florida, USA. University of Texas Health Science Center at San Antonio. Texas, USA. Society of Cardiovascular Computed Tomography; July 2006. Washington, DC Baum S, Smucluvisky C, McInnis P. Prevalence of Extra Cardiac Disease in Patients Undergoing Cardiac CTA South Florida Medical Imaging, Boca Raton, Florida, USA; Society of Cardiovascular Computed Tomography; July 2006. Washington, DC Smuclovisky C, Baum S, Dhir M, Arora UK, Mclnnis P. Evaluation of Patients With Congenital Coronary Anomalies with Cardiac CT Angiography South Florida Medical Imaging, Boca Raton, Florida; University of Texas Health Science Center at San Antonio, Texas; October 2006; North American Society for Cardiac Imaging; Las Vegas, Nevada. Morris J, Smuclovislcy C 64-slice Prospective Gated Axial Coronary CTA (PGA) In Select Patients. North American Society for Cardiac .Imaging; Scottsdale, AZ. October 2009. Khouzam, R, Smuclovisky, C. CT Angiography: Uncovering an unusual 'diagnosis in the eighth decade. Cardiology Review, January 2009, Vol. 26. No. 1. Srnuclovisky C, Morris J 64-slice Prospective Gated Axial Coronary CTA (PGA) In Select Patients. Society of Cardiovascular Computed Tomography (SCCT); Las Vegas, NV. July 2010 Invited Lecturer and Presentor: Numerous national and international CME meetings including ISET, NASCI, SCCT, Stanford MDCT; Argentina, Venezuela, UIC, Australia. Book: Coronary Artery CTA: A Case -Based Atlas Smuclovisky, Claudio 2010, XVIII, 154 p., Hardcover ISBN: 978-1-4419-0430-0 Best Doctors in America: 2007-2008 and 2009-2010 database. 6 ASSOCIATE RADIOLOGIST: INTERVENTIONAL RADIOLOGY FELLOWSHIP: C r�cl ➢eer•�eai>7rI `7 ae Ripp Smith, M.D 5201 Godfrey Road Parkland, FL 33067 (954) 345-9662 • SOUTH FLORIDA MEDICAL IMAGING FORT LAUDERDALE, FL 1997 -PRESENT CERTIFICATE ADDED QUALIFICATIO]9 VASCULAR & INTERVENTIONAL RADIOLOGY NOVEIvIBER 6, 2000 • BOARD CERTIFIED RADIOLOGY 1996 • SOUTH FLORIDA MEDICAL IMAGING I NORTHRIDGE MEDICAL CENTER FORT LAUDERDALE, FL RESIDENT RADIOLOGY: INTERNSHIP, TRANSITIONAL: MILITARY MEDICAL SERVICE, 1991-1997: • MEDICAL EDUCATION: 1996-1997 UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER DENVER, CO 1992 -1996 • PRESIDENT HOUSESTAFF ASSOCIATION 1993-1994 • DEACONESS HOSPITAL SAINT LOUIS, MO 1991-1992 • US ARMY RESERVE COLORADO ARMY NATIONAL GUARD BDE SURGEON, 169 FA BDE ▪ HONORS: THE MERITORIOUS SERVICE MEDAL FLORIDA ARMY NATIONAL GUARD BTN SURGEON, 124 INT REGT ▪ SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE SAINTLOUIS,MO: 1987-MAY 1991 • HONORS/ACT1VIT ES: BIOCHEMISTRY; PHARI\4OCOLOGY, OBSTRETRICS/GYNECOLOGY • CO -PRESIDENT OF CLASS 1987 - 1988 • M EIv1I3ER OF ADMISSIONS COMMITTEE; 1988 - 1.991 GRADUATE STUDIES: EMPLOYMENT: UNDERGRADUATE: RIPP A. SMITH., NID UNIVERSITY OF FLORIDA HUMAN NUTRITION GAINSEVILLE, FL I986-MAY 1987 • • RAINBOW NATURAL FOODS DISTRIBUTION COMPANY CO-FOUNDED NATURAL FOOD WHOLESALE DISTRIBUTION DENVER, CO .TULY 1978 - AUGUST 1986 • STANFORD UNIVERSITY STANFORD, CA 1976-1978 BACHELOR OF SCIENCE - BIOLOGY • THE UNrFED STATES MILITARY ACADEMY WEST POINT, NY 1973-1975 • HONORS: BEST NEW CADET, NEW CADET BARRACKS CLASS OF 1977 : DISTINGUISI-LED CADET (TOP 5% OF CLASS) 1973 - 1975 MILITARY SERVICE 1970 - 1973: EXPERIENCE: CURRENT AFFILIATIONS: • REPUBLIC OF VIETNAM 1971 - 1972 DECORATIONS: BRONZE STAR (THREE AWARDS) AIR MEDAL (FOUR AWARDS) PURPLE HEART (TWO AWARDS) • COMBAT INFANTRYMAN BADGE NORTERIDGE MEDICAL CENTER FORTLAUDERDALE,FL JULY 1996 -JUNE 2006 • HOLLYWOOD MEDICAL CENTER HOLLYWOOD, FL NOVEMBER 1996 - JULY 2006 PARKWAY REGIONAL MEDICAL CENTER MIAMI, EL JANUARY 2001 -JUNE 2005 CORAL GABLES HOSPITAL CORAL GABLES, FL MARCH 2002 -JUNE 2003 _HOL Y_CRO S S HOSPITAL_ _ FORT LAUDERDALE, FL JULY 2004 - PRESENT MERCY HOSPITAL MIAMI, FL JULY 2005 - PRESENT Objective Experience Education Resemcit 33 cast Camino Real, Suite 703 (561)703-2093 wort: Boca Raton FL.33432 394-9699 norm-. psiddigniGaol.com ref S ddiq , IVLD Provide general and sub specialist Radiology interpretation and review. February 2004- Current Bulging Consultants of S.E. FL Boca Raton, FL Diaanootie Radiology Attending Physician o Sub specialist practice in MRI, CT, US and Nuclear cases, July 2003- January 2004 Albany Medical Center Albany, NY Diagnostic Radiology Attending Physician o Academic sub specialist practice in NIRI, CT, US and Nuclear cases. January 2003- July 2003 Albany Medical Center Albany, NY E1odlt MPIi a Musculo-siceletl Fellowship o Training in arthrography, therapeutic injections and advanced imaging January 1999- Dec 2002 .Albany Medical Center Albany, NY [Radiology Resident ® Level 1 Trauma Center and VA hospital experiences. 1998 St Vincent's Rdedico! Center Staten Island, NY Internal iVledicine Resident 1994-1995 Meet -Prep Albany, NY Founder and President n' Successfully began and operated MCAT college preparation course 1993-1994 Princeton Review, Inc. Albany, NY Regional MCAT Director c Managed and expanded MCAT preparation course in the Albany area 1993-1997 Albany Medical College m One of 20 admitted nationwide to Accelerated 6-year program 0 M.D. degree with clinical honors obtained Albany, NY 1991-1993 Rensselaer Polytechnic institute Troy, NY Laurel onors, Biology iviinor in. -Business 'Management n Ranked 41 out of 1300 freshman year Influence of Diagnostic Dore on Subsequent 1-131 Ablation of Thyroid Remnants. Ivl.Karam, P.Siddiqui; Albany Medical College, November 2001 Presented at Society of Nuclear Medicine, L.A., Jame 2002 1.50mCi of I-131 VSUpCiiQI to 1001nCi for- the Ablation of the Thyroid Remnant. G. Gianoulialcis, Ivi.Kararn, P.Sickliqui; Albany Medical College., January 2002 Lanuilages Spadmer Spanisli PERSONAL EDUCATION Institutional Internship Michael James Rush, IU:.D. Curriculum Vitae Office Address: Office Phone: Office Fax: Date of Birth: Place of Birth: 2929 E Commercial Blvd., Suite 600 Fort Lauderdale, FL 33308 (954) 636-2290 (954) 636-5099 11-14-52 Des Moines, Iowa Page 1 of 4 o M.D., University of South Florida Medical School, Tampa, FL June 1977 o University of Southern California Medical Center, Los Angeles, CA Categorical Radiology Internship July 1977 — June 1978 Six Months Internal Medicine & General Surgery Six Months Radiology Residency o University of Southern California Medical Center, Los Angeles, CA Diagnostic Radiology Los Angeles CA July 1978- June 1981 CERTIFICATION AND LICENSURE o American Board of Radiology June 1982 o American Board of Radiology, Certificate of Added Qualification in EXPERIENCE Interventional and Vascular Radiology March 1995 and July 2004 o Florida State Board of Medical Examiners License Number ME0037889 o Medical Board of California License Number A32540 o President and Founder South Florida Medical Imaging, P.A. 1987 - Present Hollywood Medical Imaging, P.A. Nov 1996 - Present Parkway Medical Imaging, P.A. Jan 2001 - Present Coral Gables Medical Imaging, P.A. Mar 2002 - Present Private Practice in Diagnostic Radiology, Medical Imaging and Interventional Radiology at following Holy Cross Hospital Ft. Lauderdale, FL Radiologist: July 2004 — June 2005 Chief of Radiology: July 2005 — Present Michael James Rush, M.D. Curriculum Vitae (cont.) Mercy Hospital fviiami, FL Radiologist: July 2005 — Present Palmetto General Hospital Hialeah, FL Radiologist: July 1995 — September 2007 North Ridge Medical Center Ft. Lauderdale, FL Chief of Radiology: July 1989 — 2,006 Hollywood Medical Center Hollywood, FL Radiologist: November 1996 — 2006 Parkway Regional Medical Center Miami, FL Radiologist: January 2001 -- June 2005 Coral Gables Hospital Coral Gables, FL Radiologist: March 2002 — June 2003 Broward General Hospital (with South FL Medical Imaging) Ft. Lauderdale, FL Radiologist: January 1988 — March 1989 o Broward General Medical Center, Fort Lauderdale FL June 1981 — March 1989 Chief of Radiology: November 1985 — December 1987 o Paramount General Hospital, Paramount CA August 1980 -June 1981 Staff Radiologist o Riverside Hospital, North Hollywood CA July 1978 - December 1979 Emergency Room Physician SOCIETY MEMBERSHIPS o Radiological Society of North America o American College of Radiology o Society of Cardiovascular and Interventional Radiology o Southeastern Florida Radiological Society o Caducean Society Page 2 of 4 Page 3of4 Michael James Rush, N.D. Curriculum Vitae (cont.) RESEARCH ACTIVITIES o National Grant X-ray Crystallography Research, University of Florida (Summer 1973) o One of twenty physicians in U.S. to participate in Nitinol Inferior Vena Caval filters (Completed 1990) o One of six physicians in U.S. to participate in FDA protocol for placing Schneider Medical Inc. vascular wallstents o On going or recently completed FDA protocol research (last eighteen months as of October 1999) o Boston Scientific Iliac Stent trial (Symphony trial) o Schneider Wallstent peripheral venous stent trial o Schneider Wallstent central venous stent trial o Gordis 6F Hydrolyser Thrombectomy catheter (National USA Principal investigator) o Cordis 7F Hydrolyser Thrombectomy catheter (National USA Principal Investigator o Carotid stent trial (Wallstent co-authored protocol) o Cordis renal artery stent trial (Aspire II) o The US StuDy for EvalLating EndovasculaR Tre%tments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By using the Protege EverfLex Nitinol STent System II (DURABILITY II), Protocol P-2424. Sponsor: ev3 Endovascular, Inc. o GORE VIABAHN® Endoprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease (VIPER), Protocol VPR 07-03. Sponsor: W.L. Gore & Associates, Inc. o Evaluation of Dotarem® Enhanced MRA Compared to Time -of -Flight MRA in the Diagnosis of Carotid and Vertebral Basilar Arterial Disease, Protocol DGD-44-049. Sponsor: Guerbet o Evaluation of Dotarem® Enhanced MRA Compared to Time -of -Flight MRA in the Diagnosis of Renal Arterial Disease, Protocol DGD-44-047. Sponsor: Guerbet o 34 mm Infrarenal Bifurcated Stent, Protocol 07-001. Sponsor: Endologix, Inc. o Prospective aneurysm Trial: High AnGle AORfix bifurcated Stent graft, Protocol 2005-01. Sponsor: Lombard Medical Technologies, Inc. o Carotid Revascularization with ev3 Arterial Technology Evolution Post Approval Study (CREATE- PAS), Protocol P-2611. Sponsor: ev3 Endovascular, Inc. o Post Marketing Study Stenting and Angioplasty with Protection in Patients at High -Risk for Endarterectomy (SAPPHIRE-WVV), Protocol P06-3603. Sponsor__ Gordis Corporation o Gore Viabahn Endoprosthesis Versus Bare Nitinol Stent in the Treatment of Long (> 8 cm) Superficial Femoral Artery Occlusive Disease (VIBRANT), Protocol SFA 05-03. Sponsor: W. L. Gore & Associates o Emboshield and Xact Post Approval Carotid Stent Trial (EXACT), Protocol 640-0063-01. Sponsor: Abbott Vascular Page 4 o1 4 Michael dames Rush, M.D. Curriculum Vitae (cont.) o Carotid Artery Stenting with Emboli Protection Surveillance — Post Marketing Study (CASES-PMS), Protocol PO4-5204. Sponsor: Cordis Corporation o Positive Impact of Endovascular Options for Treating Aneurysm 'Early (PIVOTAL) Study, Protocol VS-2005-01. Sponsor: Medtronic / The Cleveland Clinic Foundation o Phase 1 Clinical Study of the Safety and Performance of the Relay Thoracic Stent-Graft in Patients with Thoracic Aortic Pathologies, Protocol IP-0001-04. Sponsor: Bolton Medical CONSULTANT TO SCIENTIFIC INDUSTRY o Past member, Scientific Advisory Board Pfizer -Schneider o Consultant, Abbot Laboratories (Hospital Services Division) NATIONAL PRESENTATIONS o Speaker at Vascular Workshop at annual meetings o Society of Cardiovascular and Interventional Radiology March 1995 March 1996 March 1998 March 1999 Invited March 2000 DATE: NAME: ADDRESS: TELEPHONE: CITIZENSHIP & DATE OF BIRTH: STATUS: COLLEGE: CURRICULUM \VITAE July 2010 HOWARI) ALAN RUBP'SON, M.D. 1-1ome: Office: Home: 2639 N.E. 12`h Street Fort Lauderdale, Florida 33304-1628 2929 E. Commercial Blvd. Suite 600 Fort Lauderdale, Florida 33308 (954) 565-7852 Office: (954) 609-7755 Brooklyn, New York, U.S.A. August 24, 1949 Radiologist Holy Cross Hospital Fort Lauderdale, Florida Cornell University Ithaca, New York 1967 - 1971 . Degree: A.B., June 1971 MEDICAL SCHOOL: Hahnemann Medical College (Now Drexel University School of Medicine) Philadelphia, Pennsylvania 1971 — 1975 Degree: M.D., June 1975 INTERNSHIP: Internal Medicine Internship University of Pennsylvania/ Philadelphia General Hospital Philadelphia, Pennsylvania June 20, ] 975 — June ] 8, 1976 RESIDENCY: Diagnostic Radiology Residency Department of Radiology University of Miami School of Medicine Jackson Memorial Medical Center 1\Dami, Florida July 1, 1976 — June 30, 1979 LiCENSURE: National Board of Medical Examiners — l 976 State of Florida — 1977 State of North Carolina — 2009 CERTIFICATION: Diplomate, American Board of Radiology - 1979 ACADEMIC Clinical Assistant Professor of Radiology APPOINTMENTS: Department of Radiology University of Miami School of Medicine Miami; Florida 1984 — 1986 HOSPITAL.: ,4PPOLIiTivtENTS: Assistant Professor of Radiology Department of Radiology University of Miami School of Medicine Miami, Florida 1981 — 1984 Instructor of Radiology Department of Radiology University of Miami School of Medicine Miami, Florida 1979-1981 Attending Staff Holy Cross Hospital Fort Lauderdale; Florida 2004 — Present Attending Staff 1\4ercy Hospital Miami; Florida 2005 — Present Attending Staff North Ridge Medical Center Fort Lauderdale, Florida 1989 — 2006 Attending Staff Hollywood Medical Center Hollywood; Florida 1998 — 2006 Attending Staff Parkway Regional Medical Center North Miami Beach, Florida 2001 — 2005 7 Attending Staff Coral Gables Hospital Coral Gables, Florida 2002 — 2003 Attending Staff North Beach Hospital Fort Lauderdale, Florida 1984 — 1993 Attending Staff Miami Heart Institute Miami Beach, Florida ] 981 — 1993 Attending Staff University Hospital Tamarac, Florida 1988 —1989 Attending Staff Northwest Regional Hospital Margate, Florida 1988 — 1989 Attending Staff Jackson Memorial Medical Center, University of Miami Hospital and Clinics, The Arm Bates Leach Hospital/ Bascom Palmer Eve Institute Miami, Florida 1979 — 1984 DEPARTMENTAL Director of Breast Services ADMINISTRATIVE Jeanne M. Dorini Women.'s Center RESPONSIBILITIES: Holy Cross Hospital Fort Lauderdale, Florida 2004 — Present Director of Breast Services Palmetto General Medical Center Hialeah, Florida 1995 — 2007 Medical Director North Ridge Breast Center Fort Lauderdale, Florida 1992 — 2006 3 ORGANIZATIONS: Director of Breast Services North Ridge Ivledical Center Fort Lauderdale, Florida 1992 - 2006 Director of Breast Services Hollywood Medical Center Hollywood, Florida 1996 - 2006 Director of Breast Services Parkway Regional Medical Center North Miami Beach, Florida 2001 - 2005 Chief, Radiology Services, Emergency Room Jackson Memorial Medical Center Miami, Florida 1979 - 1984 Section Chief, Chest Radiology Jackson Memorial Medical Center Miami, Florida 1979 - 1984 Director, Medical Student Education Department of Radiology University of Miami School of Medicine Miami, Florida 1980 - 1984 American College of Radiology Radiological Society of North America American Roentgen Ray Society Florida Radiological Society South Florida Radiological Society (1988 - 2002) (President-1996 - 1997, Vice President 1995 - 1996, Secretary 1994 - 1995) Florida Medical Association Broward County Medical Association Society -of -Thoracic Radiology Society of Breast imaging American Society of Emergency Radiology 4 COMMITTEES: Medical Care Review Committee North Riche 1Vl.edical Center Fort Lauderdale, Florida 1997 — 2002 Emergency Room / Disaster Conunittee North Ridge Medical Center Fort Lauderdale, Florida 1990 — 1996 Utilization Review Committee North Beach Hospital Fort Lauderdale, Florida 1985 — 1988 Emergency Room Committee Jackson Memorial Medical Center Miami, Florida 1979— 1984 Patient Care Evaluation / Utilization Review Committee Jackson Memorial Medical Center Miami, Florida 1981 — 1982 Executive Committee University of Miami Hospital and Clinics PUBLICATIONS: (TURlED JOURNALS) Miami, Florida 1980— 1981 1. Rubinson H, Isikoff M, Hill M: "Diagnostic Imaging of Hepatic. Abscesses: A Retrospective Analysis". AMERICAN JOURNAL OF ROENTGENOLOGY, 135: 735 — 740, October 1980 Pitchenik A, Rubinson H: "The Radiographic Appearance of Tuberculosis in --Patients: with,the:-- _ - - Acquired hmnune Deficiency Syndrome (AIDS) and Pre -AIDS". AMERICAN REVIEW OF RESPIRATORY DISEASES, 131: 393 — 396, 1985 5 INVITED PRESENTATJONS: ?, Moderator, Session on Chest Radiology "lnageology 1982" Department of Radiology Mount Sinai Medical Center Bal FIarbour, Florida January 1982 "Computerized Tomography of the Chest" presented at Fundamental and Clinical Aspects of Inl:ernal Medicine, Department of Medicine University of Miami School of Medicine Key Biscayne, Florida August 1982 6