J-21 Responder and Medical Record Transfer.pdf

WTC PROGRAM

National Responder Health Program (NRHP)

DATE

January 30, 2009

TITLE OF POLICY

Responder and Medical Record Transfer

PURPOSE

To outline the steps for transfer of responders and their medical records from the Medical Monitoring and Treatment Program (MMTP) in New York to the NRHP.

POLICY

Responder Transfer

When a person calls the NRHP contractor and wishes to transfer to the NRHP, the NRHP contractor must first verify enrollment by calling either the Mount Sinai School of Medicine (MSSM) Phone Bank (PB) or Fire Department of New York (FDNY). If person is not enrolled, the PB or FDNY will need to verify eligibility (see Policy 001 - Responder Eligibility).

If the person is enrolled, The NRHP contractor will work with the MSSM PB or FDNY to determine which clinics(s) the responder has attended, if any, and date of the last monitoring exam. The NRHP contractor will inform the MMTP responder that he/she will need to sign a medical record release form(s) for the transfer of their WTC-related medical records. The NRHP contractor will also create a responder record in the NRHP contractor database for processing.

Medical Record Transfer

The NRHP contractor will ensure that the responder is given the appropriate medical record release form(s) to sign (see Attachment A).

• The DCC WTC medical record release form should be used if the responder attended a non-consortium clinic.

• If the responder has had multiple visits with the last visit being performed through the MSSM DCC, then the DCC WTC release form should be used for all visits and the form forwarded to the DCC point of contact identified in Attachment A.

• The NRHP contractor will send the appropriate form(s) to the responder for signature.

• When the signed form(s) is returned, the NRHP contractor will fax the form(s) to the appropriate entity for execution.

Attachment A Summary table

Entity Record Type Form Sent to Mount Sinai Data and Coordination Center National Program

Monitoring records from non- Consortium clinical centers

DCC WTC Patient Authorization for Release of Medical Information to a Third Party

Mount Sinai Medical Center WTC Medical Monitoring and Treatment Program Data and Coordination Center One Gustave L. Levy Place, Box 1057 New York, New York 10029 Attn. Jean Weiner Phone: 212-824-7060 Fax: 212-659-8070

WTC Medical Monitoring and Treatment Program Mount Sinai Clinical Center

Monitoring records for responders examined at the Mount Sinai Medical Center

CC WTC

Patient Authorization for Release of Medical Information to a Third Party

Mount Sinai Medical Center WTC Medical Monitoring and Treatment Program 1468 Madison Avenue Annenberg Building, 3rd Floor New York, New York 10029 Attn. Pamela Outlaw, Supervisor of Medical Records Phone: 212-2451-2935 Fax: 212-426-5364

WTC Medical Monitoring and Treatment Program Mount Sinai Clinical Center

Treatment records for responders treated at Mount Sinai Medical Center

CC WTC

Patient Authorization for Release of Medical Information to a Third Party

Mount Sinai Medical Center WTC Medical Monitoring and Treatment Program 1468 Madison Avenue Annenberg Building, 3rd Floor New York, New York 10029 Attn. Christine Harris Phone: 212-241-7370 Fax: 212-426-5364

Other Consortium clinics:

NYU/Bellevue Queens

UMDNJ

Long Island

Monitoring and Treatment Records

CC WTC

Patient Authorization for Release of Medical Information to a Third Party

See Attachment B list of medical records personnel

ATTACHMENT B

The World Trade Center Medical Monitoring and Treatment Program NY/NJ Consortium Centers Contact Information for Medical Records

When a patient decides to change his/her WTC MMTP clinical center preference, refer to the following contact information for the appropriate clinical center to request the patient’s medical records from the patient's prior clinical center.

NYU/BELLEVUE CLINCIAL CENTER

Address:

Bellevue Hospital Center NYU/Bellevue Occupational & Environmental Medicine Clinic 462 First Avenue, Room CD349 New York, NY 10016

Contact Person: Jesse Duperon Contact E-mail: martiw01@med.nyu.edu Phone Number: 212-562-4572 Fax Number: 212-562-4574

Administrator: Lin Luo Phone Number: 212-562-4572 Contact E-mail: Linyong.Luo@med.nyu.edu

QUEENS CLINCIAL CENTER

Address:

The WTC Medical Monitoring and Treatment Program, Queens Clinical Center 163-03 Horace Harding Expressway, Third Floor, Suite 301 Flushing, NY 11365

Contact Person: Brooke Newman Contact E-mail: bnewman@qc.cuny.edu Phone Number: 718-670-4223 Fax Number: 718-670-4160

Administrator: Lauri Boni Contact E-mail: lboni@qc.cuny.edu Phone Number: 718-670-4191

UMDNJ CLINICAL CENTER

Address:

EOHSI/UMDNJ Clinic 170 Frelinghuysen Road, 1st Floor Piscataway, NJ 08854

Contact Person: Brenda Sookhram Contact E-mail: sookhram@eohsi.rutgers.edu Phone Number: 732-445-0123 x 600 Fax Number: 732-445-0173

Administrator: Carol Perret Contact E-mail: perretc@eohsi.rutgers.edu Phone Number: 732-445-0123 x616 mailto:martiw01@med.nyu.edu mailto:Linyong.Luo@med.nyu.edu mailto:bnewman@qc.cuny.edu mailto:lboni@qc.cuny.edu mailto:sookhram@eohsi.rutgers.edu mailto:perretc@eohsi.rutgers.edu

LONG ISLAND CLINICAL CENTER

Address:

The WTC Medical Monitoring and Treatment Program, Islandia Clinical Center 3001 Expressway Drive North, Suite 200A Islandia, NY 11749

Contact Person: Rachelle Ward Contact E-mail: rward@notes.cc.sunysb.edu Phone Number: 631-444-6436 Fax Number: 631-444-8943

Administrator: Melodie Guerrera Contact E-mail: kguerrera@notes.cc.sunysb.edu Phone Number: 631-630-2238

MOUNT SINAI CLINICAL CENTER

Address:

The WTC Medical Monitoring and Treatment Program, Mount Sinai Clinical Center 1468 Madison Avenue Annenberg Building, 3rd Floor New York, New York 10029

Administrator: Matt Cassidy Contact E-mail: matthew.cassidy@mssm.edu Phone Number: 212-241-9788

Monitoring Records Primary Contact Person: Pamela Outlaw, Supervisor of Medical Records Contact E-mail: pamela.outlaw@mssm.edu Phone Number: 212-241-2935 Fax Number: 212-426-5364 Secondary Contact People: Lenore Shallow (212-241-2957), and/or Sheik Wiltshire (212-241-4267) Treatment Records Primary Contact Person: Christine Harris, Administrative Manager Treatment Program Contact E-mail: christine.harris@mssm.edu Phone Number: 212-241-7370 Fax Number: 212-987-1134

MOUNT SINAI WTC DATA AND COORDINATION CENTER

Address:

WTC Medical Monitoring and Treatment Program Data and Coordination Center Mount Sinai Medical Center One Gustave L. Levy Place, Box 1057 New York, NY 10029

Administrator: Jean Weiner Contact E-mail: jean.weiner@mssm.edu Phone Number: 212-824-7060

Primary Contact Person: Maria Bonet Contact E-mail: maria.bonet@mssm.edu Phone Number: 212-824-7379 Fax: 212-659-8070 mailto:kguerrera@notes.cc.sunysb.edu mailto:matthew.cassidy@mssm.edu mailto:pamela.outlaw@mssm.edu mailto:christine.harris@mssm.edu mailto:jean.weiner mailto:maria.bonet@mssm.edu