Notice of Privacy Practices

Effective Date:  April 14, 2003

THIS 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.

We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice that describes the health information privacy practices of our nursing home, hospital, medical staffs, and affiliated health care providers that jointly provide health care services with our nursing home and hospital.  A copy of our current notice will always be posted in our reception area.  You will also be able to obtain your own copies by accessing our website at www.saintjosephs.org or by calling our office at 914-378-7514 or asking for one at the time of your next visit.

If you have any questions about this notice or would like further information,
please contact the Privacy Officer at 914-378-7514.

WHO WILL FOLLOW THIS NOTICE?

Saint Joseph’s Medical Center provides health care to patients and
nursing home residents jointly with physicians and other health care professionals
and organizations.  The privacy practices described in this notice will
be followed by:
• Every health care professional who treats you at any of our locations,*
• All employees, medical staff, trainees, students or volunteers at all
Saint Joseph’s Medical Center locations, including St. Vincent's Hospital Westchester, St. Joseph’s Nursing Home and St. Joseph’s Hospital, its clinics and outpatient departments;

• Any business associates of our hospital (which are described further below).

The participants in an Organized Health Care Arrangement share information
with each other as necessary to carry out treatment, payment and health care
operations related to the Organized Health Care Arrangement.

PERMISSIONS DESCRIBED IN THIS NOTICE

This notice will explain the different types of permission we will obtain
from you before we use or disclose your health information for a variety
of purposes.  The three types of permissions referred to in this notice
are:

• A “general written consent,” which we must obtain from
you in order to use and disclose your health information in order to treat
you, obtain payment for that treatment, and conduct our business operations.  We
must obtain this general written consent the first time we provide you with
treatment or services.  This general written consent is a broad permission
that does not have to be repeated each time we provide treatment or services
to you.

• An “opportunity to object,” which we must provide to
you before we may use or disclose your health information for certain purposes.  In
these situations, you will have an opportunity to object to the use or disclosure
of your health information in person, over the phone, or in writing.

• A “written authorization,” which will provide you with
detailed information about the persons who may receive your health information
and the specific purposes for which your health information may be used or
disclosed.  We are only permitted to use and disclose your health information
described on the written authorization in ways that are explained on the
written authorization form you have signed.  A written authorization
will have an expiration date.

IMPORTANT SUMMARY INFORMATION

Requirement For Written Authorization.  We will generally obtain your
written authorization before using your health information or sharing it
with others outside the hospital.  You may also initiate the transfer
of your records to another person by completing a written authorization form.  If
you provide us with written authorization, you may revoke that written authorization
at any time, except to the extent that we have already relied upon it.  To
revoke a written authorization, please write to the Director of Health Information
Management.  

Exceptions To Written Authorization Requirement.  There are some situations
when we do not need your written authorization before using your health information
or sharing it with others.  They are:

• Exception For Treatment, Payment, And Business Operations.  We will
only obtain your general written consent one time to use and disclose your health
information to treat your condition, collect payment for that treatment, or run
our business operations.  In some cases, we also may disclose your health
information to another health care provider or payor for its payment activities
and certain of its business operations.  For more information, see pages
5-6 of this notice.

 
• Exception For Patient Directory And Disclosure To Family And Friends Involved
In Your Care.  We will ask you whether you have any objection to including
information about you in our Patient Directory or sharing information about your
health with your friends and family involved in your care.  For more information,
see page 7 of this notice.

• Exception In Emergencies Or Public Need.  We may use or disclose
your health information in an emergency or for important public needs.  For
example, we may share your information with public health officials at the
New York State or city health departments who are authorized to investigate
and control the spread of diseases.  For more examples, see pages 7-10
of this notice.

• Exception If Information Is Completely Or Partially De-Identified.  We
may use or disclose your health information if we have removed any information
that might identify you so that the health information is “completely
de-identified.”  We may also use and disclose “partially
de-identified” information if the person who will receive the information
agrees in writing to protect the privacy of the information.  For more
information, please see page 10 of this notice.

How To Access Your Health Information.  You generally have the right
to inspect and copy your health information.  For more information,
please see page 11 of this notice.

How To Correct Your Health Information.  You have the right to request
that we amend your health information if you believe it is inaccurate or
incomplete.  For more information, please see page 11 of this notice.

How To Identify Others Who Have Received Your Health Information.  You
have the right to receive an “accounting of disclosures,” which
identifies certain persons or organizations to whom we have disclosed your
health information in accordance with the protections described in this Notice
of Privacy Practices.  Many routine disclosures we make will not be
included in this accounting, but the accounting will identify many non-routine
disclosures of your information.  For more information, please see page 12
of this notice.

How To Request Additional Privacy Protections.  You have the right
to request further restrictions on the way we use your health information
or share it with others.  We are not required to agree to the restriction
you request, but if we do, we will be bound by our agreement.  For more
information, please see page 13 of this notice.           

How To Request More Confidential Communications.  You have the right
to request that we contact you in a way that is more confidential for you,
such as at home instead of at work.  We will try to accommodate all
reasonable requests.  For more information, please see page 13
of this notice.

How Someone May Act On Your Behalf.  You have the right to name a personal
representative who may act on your behalf to control the privacy of your
health information.  Parents and guardians will generally have the right
to control the privacy of health information about minors unless the minors
are permitted by law to act on their own behalf.

How To Learn About Special Protections For HIV, Alcohol and Substance Abuse,
Mental Health And Genetic Information.  Special privacy protections
apply to HIV-related information, alcohol and substance abuse treatment information,
mental health information, and genetic information.  Some parts of this
general Notice of Privacy Practices may not apply to these types of information.  If
your treatment involves this information, you will be provided with separate
notices explaining how the information will be protected.  To request
copies of these other notices now, please contact the Director of Health
Information Management at 914-378-7637.

How To Obtain A Copy Of This Notice.  You have the right to a paper
copy of this notice.  You may request a paper copy at any time, even
if you have previously agreed to receive this notice electronically.  To
do so, please call the Privacy Officer at 914-378-7514.  You may also
obtain a copy of this notice from our website at www.saintjosephs.org  or
by requesting a copy at your next visit.

How To Obtain A Copy Of Revised Notice.  We may change our privacy
practices from time to time.  If we do, we will revise this notice so
you will have an accurate summary of our practices.  The revised notice
will apply to all of your health information.  We will post any revised
notice in our hospital reception area.  You will also be able to obtain
your own copy of the revised notice by accessing our website at www.saintjosephs.org  calling
our office at 914-378-7514 or asking for one at the time of your next visit.  The
effective date of the notice will always be noted in the top right corner
of the first page.  We are required to abide by the terms of the notice
that is currently in effect.

How To File A Complaint.  If you believe your privacy rights have been
violated, you may file a complaint with us or with the Secretary of the Department
of Health and Human Services.  To file a complaint with us, please contact
Mary O’Mara, Vice President, Saint Joseph’s Medical Center, 127
South Broadway, Yonkers, New York 10701, 914-378-7514.  No one will
retaliate or take action against you for filing a complaint.

WHAT HEALTH INFORMATION IS PROTECTED

We are committed to protecting the privacy of information we gather about
you while providing health-related services.  Some examples of protected
health information are:

• information indicating that you are a patient at the hospital or receiving
treatment or other health-related services from our hospital;

• information about your health condition (such as a disease you may
have);

• information about health care products or services you have received
or may receive in the future (such as an operation); or

• information about your health care benefits under an insurance plan
(such as whether a prescription is covered);

when combined with: 

• demographic information (such as your name, address, or insurance
status);

• unique numbers that may identify you (such as your social security
number, your phone number, or your driver’s license number); and

• other types of information that may identify who you are. 

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

1. Treatment, Payment And Business Operations 

With your general written consent, we may use your health information or
share it with others in order to treat your condition, obtain payment for
that treatment, and run our business operations.  In some cases, we
may also disclose your health information for payment activities and certain
business operations of another health care provider or payor.  Below
are further examples of how your information may be used and disclosed for
these purposes.

Treatment. 
We may share your health information with doctors or nurses at the hospital
who are involved in taking care of you, and they may in turn use that information
to diagnose or treat you.  A doctor at our hospital may share your
health information with another doctor inside our hospital, or with a doctor
at another hospital, to determine how to diagnose or treat you.  Your
doctor may also share your health information with another doctor to whom
you have been referred for further health care.

Payment.
We may use your health information or share it with others so that we may
obtain payment for your health care services.  For example, we may
share information about you with your health insurance company in order
to obtain reimbursement after we have treated you, or to determine whether
it will cover your treatment.  We might also need to inform your health
insurance company about your health condition in order to obtain pre-approval
for your treatment, such as admitting you to the hospital for a particular
type of surgery.  Finally, we may share your information with other
health care providers and payors for their payment activities.

Business Operations. 
We may use your health information or share it with others in order to conduct
our business operations.  For example, we may use your health information
to evaluate the performance of our staff in caring for you, or to educate
our staff on how to improve the care they provide for you.  Finally,
we may share your health information with other health care providers and
payors for certain of their business operations if the information is related
to a relationship the provider or payor currently has or previously had
with you, and if the provider or payor is required by federal law to protect
the privacy of your health information.

Appointment Reminders, Treatment Alternatives, Benefits And Services. 
In the course of providing treatment to you, we may use your health information
to contact you with a reminder that you have an appointment for treatment
or services at our facility.  We may also use your health information
in order to recommend possible treatment alternatives or health-related
benefits and services that may be of interest to you.

Fundraising. 
To support our business operations, we may use demographic information about
you, including information about your age and gender, where you live or
work, and the dates that you received treatment, in order to contact you
to raise money to help us operate.  We may also share this information
with a charitable foundation that will contact you to raise money on our
behalf.

Business Associates. 
We may disclose your health information to contractors, agents and other
business associates who need the information in order to assist us with
obtaining payment or carrying out our business operations.  For example,
we may share your health information with a billing company that helps
us to obtain payment from your insurance company.  Another example
is that we may share your health information with an accounting firm or
law firm that provides professional advice to us about how to improve our
health care services and comply with the law.  If we do disclose your
health information to a business associate, we will have a written contract
to ensure that our business associate also protects the privacy of your
health information.

We can do all of these things if you have signed a general written consent
form.  Once you sign this general written consent form, it will be in
effect indefinitely until you revoke your general written consent.  You
may revoke your general written consent at any time, except to the extent
that we have already relied upon it.  For example, if we provide you
with treatment before you revoke your general written consent, we may still
share your health information with your insurance company in order to obtain
payment for that treatment.  To revoke your general written consent,
please write to the Director of Health Information Management. 

2. Patient Directory/Family and Friends

We may use your health information in, and disclose it from, our Patient
Directory, or share it with family and friends involved in your care, without
your written authorization.  We will always give you an opportunity
to object unless there is insufficient time because of a medical emergency
(in which case we will discuss your preferences with you as soon as the emergency
is over).  We will follow your wishes unless we are required by law
to do otherwise.

Patient Directory. 
If you do not object, we will include your name, your location in our facility,
your general condition (e.g., fair, stable, critical, etc.) and your religious
affiliation in our Patient Directory while you are a patient in the hospital
or one of the facilities described at the beginning of this notice.  This
directory information, except for your religious affiliation, may be released
to people who ask for you by name.  Your religious affiliation may
be given to a member of the clergy, such as a priest or rabbi, even if
he or she doesn’t ask for you by name.

Family and Friends Involved In Your Care. 
If you do not object, we may share your health information with a family
member, relative, or close personal friend who is involved in your care
or payment for that care.  We may also notify a family member, personal
representative or another person responsible for your care about your location
and general condition here at the hospital, or about the unfortunate event
of your death.  In some cases, we may need to share your information
with a disaster relief organization that will help us notify these persons.

3. Emergencies Or Public Need

We may use your health information, and share it with others, in order to
treat you in an emergency or to meet important public needs.  We will
not be required to obtain your general written consent before using or disclosing
your information for these reasons.  We will, however, obtain your written
authorization for, or provide you with an opportunity to object to, the use
and disclosure of your health information in these situations when state
law specifically requires that we do so.

Emergencies.
We may use or disclose your health information if you need emergency treatment
or if we are required by law to treat you but are unable to obtain your
general written consent.  If this happens, we will try to obtain your
general written consent as soon as we reasonably can after we treat you.

Communication Barriers.
We may use and disclose your health information if we are unable to obtain
your general written consent because of substantial communication barriers,
and we believe you would want us to treat you if we could communicate with
you.

As Required By Law.

We may use or disclose your health information if we are required by law
to do so.  We also will notify you of these uses and disclosures if
notice is required by law.

Public Health Activities.
We may disclose your health information to authorized public health officials
(or a foreign government agency collaborating with such officials) so they
may carry out their public health activities.   For example,
we may share your health information with government officials that are
responsible for controlling disease, injury or disability.  We may
also disclose your health information to a person who may have been exposed
to a communicable disease or be at risk for contracting or spreading the
disease if a law permits us to do so.  And finally, we may release
some health information about you to your employer if your employer hires
us to provide you with a physical exam and we discover that you have a
work-related injury or disease that your employer must know about in order
to comply with employment laws. 

Victims Of Abuse, Neglect Or Domestic Violence.
We may release your health information to a public health authority that
is authorized to receive reports of abuse, neglect or domestic violence.  For
example, we may report your information to government officials if we reasonably
believe that you have been a victim of such abuse, neglect or domestic
violence.  We will make every effort to obtain your permission before
releasing this information, but in some cases we may be required or authorized
to act without your permission.

Health Oversight Activities.
We may release your health information to government agencies authorized
to conduct audits, investigations, and inspections of our facility.  These
government agencies monitor the operation of the health care system, government
benefit programs such as Medicare and Medicaid, and compliance with government
regulatory programs and civil rights laws.

Product Monitoring, Repair And Recall.
We may disclose your health information to a person or company that is regulated
by the Food and Drug Administration for the purpose of: (1) reporting or
tracking product defects or problems; (2) repairing, replacing, or recalling
defective or dangerous products; or (3) monitoring the performance of a
product after it has been approved for use by the general public.

Lawsuits And Disputes.
We may disclose your health information if we are ordered to do so by a court
or administrative tribunal that is handling a lawsuit or other dispute.

Law Enforcement.
We may disclose your health information to law enforcement officials for
the following reasons:

• To comply with court orders or laws that we are required to follow;

• To assist law enforcement officers with identifying or locating a
suspect, fugitive, witness, or missing person;

• If you have been the victim of a crime and we determine that: (1)
we have been unable to obtain your general written consent because of an
emergency or your incapacity; (2) law enforcement officials need this information
immediately to carry out their law enforcement duties; and (3) in our professional
judgment disclosure to these officers is in your best interests;

• If we suspect that your death resulted from criminal conduct;

• If necessary to report a crime that occurred on our property; or

• If necessary to report a crime discovered during an offsite medical
emergency (for example, by emergency medical technicians at the scene of
a crime).

To Avert A Serious And Imminent Threat To Health Or Safety. 
We may use your health information or share it with others when necessary
to prevent a serious and imminent threat to your health or safety, or the
health or safety of another person or the public.  In such cases,
we will only share your information with someone able to help prevent the
threat.  We may also disclose your health information to law enforcement
officers if you tell us that you participated in a violent crime that may
have caused serious physical harm to another person (unless you admitted
that fact while in counseling), or if we determine that you escaped from
lawful custody (such as a prison or mental health institution).

National Security And Intelligence Activities Or Protective Services. 

We may disclose your health information to authorized federal officials who
are conducting national security and intelligence activities or providing
protective services to the President or other important officials.

Military And Veterans. 
If you are in the Armed Forces, we may disclose health information about
you to appropriate military command authorities for activities they deem
necessary to carry out their military mission.  We may also release
health information about foreign military personnel to the appropriate
foreign military authority.

Inmates And Correctional Institutions.  
If you are an inmate or you are detained by a law enforcement officer, we
may disclose your health information to the prison officers or law enforcement
officers if necessary to provide you with health care, or to maintain safety,
security and good order at the place where you are confined.  This
includes sharing information that is necessary to protect the health and
safety of other inmates or persons involved in supervising or transporting
inmates.

Workers’ Compensation. 
We may disclose your health information for workers’ compensation or
similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners And Funeral Directors. 
In the unfortunate event of your death, we may disclose your health information
to a coroner or medical examiner.  This may be necessary, for example,
to determine the cause of death.  We may also release this information
to funeral directors as necessary to carry out their duties.

Organ And Tissue Donation.
In the unfortunate event of your death, we may disclose your health information
to organizations that procure or store organs, eyes or other tissues so
that these organizations may investigate whether donation or transplantation
is possible under applicable laws.

Research. 
In most cases, we will ask for your written authorization before using your
health information or sharing it with others in order to conduct research.  However,
under some circumstances, we may use and disclose your health information
without your written authorization if we obtain approval through a special
process to ensure that research without your written authorization poses
minimal risk to your privacy.  Under no circumstances, however, would
we allow researchers to use your name or identity publicly.  We may
also release your health information without your written authorization
to people who are preparing a future research project, so long as any information
identifying you does not leave our facility.  In the unfortunate event
of your death, we may share your health information with people who are
conducting research using the information of deceased persons, as long
as they agree not to remove from our facility any information that identifies
you.

4. Completely De-identified Or Partially De-identified Information.

We may use and disclose your health information if we have removed any information
that has the potential to identify you so that the health information is “completely
de-identified.”  We may also use and disclose “partially
de-identified” health information about you if the person who will
receive the information signs an agreement to protect the privacy of the
information as required by federal and state law.  Partially de-identified
health information will not contain any information that would directly identify
you (such as your name, street address, social security number, phone number,
fax number, electronic mail address, website address, or license number).

 5. Incidental Disclosures

While we will take reasonable steps to safeguard the privacy of your health
information, certain disclosures of your health information may occur during
or as an unavoidable result of our otherwise permissible uses or disclosures
of your health information.  For example, during the course of a treatment
session, other patients in the treatment area may see, or overhear discussion
of, your health information.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control
your health information.  These rights are important because they will
help you make sure that the health information we have about you is accurate.  They
may also help you control the way we use your information and share it with
others, or the way we communicate with you about your medical matters.

1. Right To Inspect And Copy Records

You have the right to inspect and obtain a copy of any of your health information
that may be used to make decisions about you and your treatment for as long
as we maintain this information in our records.  This includes medical
and billing records.  To inspect or obtain a copy of your health information,
please submit your request in writing to the 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 we use to fulfill
your request.  The standard fee is $0.75 per page and must generally
be paid before or at the time we give the copies to you.

We will respond to your request for inspection of records within 10 days.
We ordinarily will respond to requests for copies within 30 days if the information
is located in our facility, and within 60 days if it is located off-site
at another facility.  If we need additional time to respond to a request
for copies, we will notify you in writing within the time frame above to
explain the reason for the delay and when you can expect to have a final
answer to your request.

Under certain very limited circumstances, we may deny your request to inspect
or obtain a copy of your information.  If we do, we will provide you
with a summary of the information instead.  We will also provide a written
notice that explains our reasons for providing only a summary, and a complete
description of your rights to have that decision reviewed and how you can
exercise those rights.  The notice will also include information on
how to file a complaint about these issues with us or with the Secretary
of the Department of Health and Human Services.  If we have reason to
deny only part of your request, we will provide complete access to the remaining
parts after excluding the information we cannot let you inspect or copy.

2. Right To Amend Records

If you believe that the health 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 in our
records.  To request an amendment, please write to the Director of Health
Information Management.  Your request should include the reasons why
you think we should make the amendment.  Ordinarily we will respond
to your request within 60 days.  If we need additional time to respond,
we will notify you in writing within 60 days to explain the reason for the
delay and when you can expect to have a final answer to your request.

If we deny part or all of your request, we will provide a written notice
that explains our reasons for doing so.  You will have the right to
have certain information related to your requested amendment included in
your records.  For example, if you disagree with our decision, you will
have an opportunity to submit a statement explaining your disagreement which
we will include in your records.  We will also include information on
how to file a complaint with us or with the Secretary of the Department of
Health and Human Services.  These procedures will be explained in more
detail in any written denial notice we send you.

3. Right To An Accounting Of Disclosures

After April 14, 2003, you have a right to request an “accounting of
disclosures” which identifies certain other persons or organizations
to whom we have disclosed your health information in accordance with applicable
law and the protections afforded in this Notice of Privacy Practices.  An
accounting of disclosures does not describe the ways that your health information
has been shared within and between the hospital and the facilities described
at the beginning of this notice, as long as all other protections described
in this Notice of Privacy Practices have been followed (such as obtaining
the required approvals before sharing your health information with our doctors
for research purposes).

An accounting of disclosures also does not include information about the
following disclosures:

• Disclosures we made to you or your personal representative;

• Disclosures we made pursuant to your written authorization;

• Disclosures we made for treatment, payment or business operations;

• Disclosures made from the patient directory;

• Disclosures made to your friends and family involved in your care
or payment for your care;

• Disclosures that were incidental to permissible uses and disclosures
of your health information (for example, when information is overheard by
another patient passing by);

• Disclosures for purposes of research, public health or our business
operations of limited portions of your health information that do not directly
identify you;

• Disclosures made to federal officials for national security and intelligence
activities;

• Disclosures about inmates to correctional institutions or law enforcement
officers;

• Disclosures made before April 14, 2003.

To request an accounting of disclosures, please write to the Director of
Health Information Management.  Your request must state a time period
within the past six years (but after April 14, 2003) for the disclosures
you want us to include.  For example, you may request a list of the
disclosures that we made between January 1, 2004 and January 1, 2005.  You
have a right to receive one accounting within every 12 month period for free.  However,
we may charge you for the cost of providing any additional accounting in
that same 12 month period.  We will always notify you of any cost involved
so that you may choose to withdraw or modify your request before any costs
are incurred.

Ordinarily we will respond to your request for an accounting within 60 days.  If
we need additional time to prepare the accounting you have requested, we
will notify you in writing about the reason for the delay and the date when
you can expect to receive the accounting.  In rare cases, we may have
to delay providing you with the accounting without notifying you because
a law enforcement official or government agency has asked us to do so.

4. Right To Request Additional Privacy Protections

You have the right to request that we further restrict the way we use and
disclose your health information to treat your condition, collect payment
for that treatment, or run our business operations.  You may also request
that we limit how we disclose information about you to family or friends
involved in your care.  For example, you could request that we not disclose
information about a surgery you had.  To request restrictions, please
write to the Director of Health Information Management.  Your request
should include (1) what information you want to limit; (2) whether you want
to limit how we use the information, how we share it with others, or both;
and (3) to whom you want the limits to apply. 

We are not required to agree to your request for a restriction, and in some
cases the restriction you request may not be permitted under law.  However,
if we do agree, we will be bound by our agreement unless the information
is needed to provide you with emergency treatment or comply with the law.  Once
we have agreed to a restriction, you have the right to revoke the restriction
at any time.  Under some circumstances, we will also have the right
to revoke the restriction as long as we notify you before doing so; in other
cases, we will need your permission before we can revoke the restriction.

5. Right To Request Confidential Communications

You have the right to request that we communicate with you about your medical
matters in a more confidential way by requesting that we communicate with
you by alternative means or at alternative locations.  For example,
you may ask that we contact you at home instead of at work.  To request
more confidential communications, please write to the Director of Health
Information Management.  We will not ask you the reason for your request,
and we will try to accommodate all reasonable requests.  Please specify
in your request how or where you wish to be contacted, and how payment for
your health care will be handled if we communicate with you through this
alternative method or location

ACKNOWLEDGMENT AND CONSENT

By signing below, I acknowledge that I have been provided a copy of this
Notice of Privacy Practices and have therefore been advised of how health
information about me may be used and disclosed by the hospital and the facilities
listed at the beginning of this notice, and how I may obtain access to and
control this information.  I also acknowledge and understand that I
may request copies of separate notices explaining special privacy protections
that apply to HIV-related information, alcohol and substance abuse treatment
information, mental health information, and genetic information. Finally,
by signing below, I consent to the use and disclosure of my health information
to treat me and arrange for my medical care, to seek and receive payment
for services given to me, and for the business operations of the hospital,
its staff, and the facilities described at the beginning of this notice.
 

_________________________________________
Signature of Patient or Personal Representative

_________________________________________
Print Name of Patient or Personal Representative

_________________________________________
Date

_________________________________________

Description of Personal Representative’s Authority

* (St. Joseph’s Nursing Home and St. Joseph’s Hospital participate
in Organized Health Care Arrangements with independent providers.

Saint Joseph's Medical Center

127 South Broadway, Yonkers, NY 10701
Telephone: (914) 378-7000