Continuum Health Partners

CONTINUUM HEALTH PARTNERS Physician Profile Fact Sheet

All physicians affiliated with any one of the Continuum Health Partners hospitals are invited to complete this Profile Fact Sheet. The information on this fact sheet is made available to the public on Continuum’s web site, www.chpnyc.org. Additionally, it is used by individuals who call our Physician Referral Center (800-420-4004) for a medical referral and for Continuum’s Physician Telephone Directory.

In addition to this form, we need a copy of your CV. Please send this form and your CV, by fax or email to: Ms. Janice Boylan Continuum Referral Service 555 West 57th Street, 18th floor New York, NY 10019 Phone: (212) 844-1844 Fax: (212) 420-2180 [email protected] ______New Listing Change in current information Please post my information on Continuum’s Web site, www.chpnyc.org Please include my information in the medical referrals you provide at the Physician Referral Service

Last Name: ______First Name: ______Middle Initial: ______E-Mail: To facilitate faster and more efficient communications with members of the medical staff, we ask that you provide your E-mail address. Please be assured that your e-mail address will be used strictly for internal communications, unless you indicate that it should be posted on our Web site. We will not share your E-mail address with any outside source.

Your E-mail address: ______Do not post on chpnyc.org Post on chpnyc.org for public viewing ______

Professional Certification (MD, DDS, DO, etc.) ______Gender: Male Female

Board Certified: Yes No Board Name: ______Board Name: ______Year Certified: ______Year Certified: ______Year Recertified: ______Year Recertified: ______

Board Certified: Yes No ______

Hospital Affiliation(s): BI (Petrie) BI (KHD) SLR LICH NYEEI Department: ______Specialty: (Primary) ______Specialty: (Secondary) ______Clinical Interest(s): ______

Medical Staff Rank and/or Title(s): Check all that apply. Titles refer only to Continuum hospitals.  Chairman, Department of: ______ Chief, Division of: ______ Director, (Center) : ______ Attending: ______ Other: ______

Academic Appointments: Indicate academic titles only for institutions listed below. Albert Einstein College of Medicine Columbia University College of Physicians and Surgeons SUNY Health Science Center (Brooklyn) New York Medical College

Title: ______Department: ______

Medical School: ______Location: ______Year Graduated: ______

Residency Program: ______From: ______(year) to ______(year) Location (hospital, city, state): ______

Fellowship: ______From: ______(year) to ______(year) Location (hospital, city, state) ______

If you wish, you may attach a photo for our Web site, www.chpnyc.org Photo attached: Yes No ______

Office Information: Please complete for each office in which you practice. Attach any additional information.

Office Address 1 Office Address 2 Practice Name: ______Practice Name: ______Street: ______Street: ______City: ______State: _____ Zip: _____ City: ______State: _____ Zip: _____ Telephone: ______Telephone: ______Fax: ______Fax: ______Office Manager/ Phone: ______Office Manager/ Phone: ______

Office Schedule Office Schedule Monday _____ to _____ Monday _____ to _____ Tuesday _____ to _____ Tuesday _____ to _____ Wednesday _____ to _____ Wednesday _____ to _____ Thursday _____ to _____ Thursday _____ to _____ Friday _____ to _____ Friday _____ to _____ Saturday _____ to _____ Saturday _____ to _____ Sunday _____ to _____ Sunday _____ to _____

Are you willing to see emergency cases? Yes No Are you willing to make housecalls? Yes No Are you in a group practice? Yes No If yes, please list other physicians’ names: ______Please note any specific equipment you have on site (e.g., X-ray, sonogram)? ______Is your office handicap accessible? Yes No Please list any languages you speak other than English: ______Please list any languages your staff speaks other than English: ______Do you accept children? Yes No If yes, what is the youngest age? ______

Payment Information Please provide us with a listing of all of the insurance plans you accept. Be sure to include information as to whether you accept Medicare and/or Medicaid, including any managed-care Medicare/Medicaid plans.

Initial visit fee $ ______Subsequent visit fee $ ______

Do you require payment at time of service? Yes No Do you accept Medicare as a primary payor ? Yes No Do you accept Medicaid as a primary payor? Yes No If no, do you accept Medicaid as a secondary payor? Yes No Please check any insurance plans you accept: (Attach additional page if necessary) 1199 EMPIRE BLUE HOTEL TRADE UNION 32 BJ CROSS/BLUE SHIELD EPO HUMANA ACADEMIC HEALTH EMPIRE BLUE LOCAL 814 PLAN (Yeshiva Students) CROSS/BLUE SHIELD HMO MAGNACARE AETNA CHICKERING EMPIRE BLUE MASTERCARE (Columbia University Student CROSS/BLUE SHIELD MEDICAID Insurance) INDEMNITY MEDICAID SECONDARY AETNA MEDICARE EMPIRE BLUE TO MEDICARE AETNA NYC CROSS/BLUE SHIELD MEDICARE COMMUNITY PLAN MEDIBLUE (Medicare) METROPLUS CHILD AETNA OPEN ACCESS EMPIRE BLUE HEALTH PLUS HMO CROSS/BLUE SHIELD PPO METROPLUS FAMILY AETNA PPO FAMILY HEALTH PLUS HEALTH PLUS AFFINITY CHILD FIDELIS CHILD HEALTH METROPLUS MEDICAID HEALTH PLUS PLUS METROPLUS MEDICARE AFFINITY FAMILY FIDELIS FAMILY MULTIPLAN (includes HEALTH PLUS HEALTH PLUS Allied) AFFINITY MEDICAID FIDELIS MEDICAID NEIGHBORHOOD CHILD AFFINITY MEDICARE FIDELIS MEDICARE HEALTH PLUS AMERICHOICE (United FIRST HEALTH NEIGHBORHOOD Medicaid) GALAXY FAMILY HEALTH PLUS AMERICHOICE CHILD GHI HMO CHILD HEALTH NEIGHBORHOOD HEALTH PLUS PLUS MEDICAID AMERICHOICE FAMILY GHI HMO COMMERCIAL NEIGHBORHOOD HEALTH PLUS GHI HMO FAMILY MEDICARE AMERIGROUP CHILD HEALTH PLUS NO FAULT HEALTH PLUS GHI HMO MEDICAID ONE HEALTH PLAN (Great AMERIGROUP FAMILY GHI PPO (CBP For NYC West/New England) HEALTH PLUS Employees & Medicare) OXFORD FREEDOM AMERIGROUP GREAT WEST (formerly OXFORD LIBERTY MEDICAID One Health) OXFORD MEDICARE AMERIHEALTH GUARDIAN (Secure Horizons) ANTHEM HEALTHFIRST CHILD PHYSICIANS HEALTH ATLANTIS HMO HEALTH PLUS SERVICE (Healthnet) BC/BS OF NY (Major HEALTHFIRST FAMILY PRIVATE HEALTHCARE Medical) HEALTH PLUS SYSTEMS (PHCS) BEECH STREET HEALTHFIRST MEDICAID RAILROAD MEDICARE BETTER HEALTH HEALTHFIRST SELECT PRO ADVANTAGE MEDICARE UNITED HEALTHCARE CAMBRIDGE HEALTHNET (formerly UNITED HEALTHCARE CENTERCARE CHILD PHS) EMPIRE PLAN HEALTH PLUS HEALTHPLUS CHILD UNITED HEALTHCARE CENTERCARE FAMILY HEALTH PLUS HMO HEALTH PLUS HEALTHPLUS FAMILY UNITED HEALTHCARE CENTERCARE HEALTH PLUS MEDICAID (Americhoice) MEDICAID HEALTH PLUS MEDICAID UNITED HEALTHCARE CHILD HEALTH PLUS HIP CHILD HEALTH PLUS MEDICARE (Secure Horizons) CHN HIP FAMILY HEALTH UNITED HEALTHCARE CIGNA PLUS PPO CIGNA HMO (Open Access) HIP HMO VIDACARE CIGNA PPO HIP MEDICAID WELLCARE CHILD COMPREHENSIVE CARE HIP PPO HEALTH PLUS MANAGEMENT HIP VIP (Medicare) WELLCARE FAMILY COST CARE HIP/VYTRA HEALTH PLUS DELTA DENTAL HORIZON BLUE CROSS WELLCARE MEDICAID ELDERPLAN BLUE SHIELD OF NJ WORKER’S COMP OTHER OTHER OTHER OTHER OTHER

In addition to this form, we need a copy of your CV. Please send this form and your CV to: Ms. Janice Boylan Continuum Referral Service 555 West 57th Street, 18th floor New York, NY 10019 Fax: (212) 420-2180 [email protected]

I authorize Continuum Health Partners, Inc. to give my name and credentials to members of the community who seek health care services.

Physician signature ______Date ______

If you have a short biographical sketch that you would like to appear on your Web profile, please email it to Janice Boylan at [email protected].