f orum

Derek tenhoopen, md
Kevin Casey, MD
Cynthia Christy, MD
Ronald Sham, MD
Past President
Elected Representatives:
Matthew Fleig, MD
John Hix, MD
Claudia Hriesik, MD
Kevin McGrody, MD
James Szalados, MD
Balazs Zsenits, MD
Editorial Staff:
Derek tenHoopen, MD, Editor
2014 Quarterly Staff Dates
• December 19
2015 Quarterly Staff Dates
• March 20
• September 18
• June 19
• December 18
Twig Conference Room
7:30 – 8:30 a.m. for all meetings
50% attendance recommended
for all attending Physicians
November 2014
a newsletter by the medical & dental staff of Roch general hospital
more of your monthly updates can be found at
Message from RGH MDS President
Knowledge Management–
A Key Component in Any Merger
Derek tenHoopen, MD, RGH MDS President
nowledge Management (KM) involves the
manipulation of knowledge, information
and data. The hierarchy is structured in the
following way…” data becomes information when
it is organized; information becomes knowledge
when it is placed in actionable context” (1).
Leaders in the field of Knowledge Management
believe that this it is in fact “the third phase” of the
Industrial Revolution. Knowledge, including its
Derek tenHoopen, md
use, distribution, application and exploitation, is
RGH MDS President
the new driving force of the global economy.
The website “destinationKM.com” uses the following definition
for KM: “Knowledge Management refers to strategies and structures
for maximizing the return on intellectual and information resources…it
resides both in tacit form (human education, experience and expertise)
and explicit form (documents and data); KM depends on both cultural
and technologic processes of creation, collection, recombination and
Several authors relate this definition to the corporate world.
“Knowledge Management is the practice of harnessing and exploiting
intellectual capital to gain competitive and customer commitment
through efficiency, innovation and faster and more effective decision
Why discuss Knowledge Management now?
In the health care environment, KM is the practice of harnessing and
exploiting intellectual capital to ensure best practices, quality care, and
patient safety through efficiency, innovation, faster and more effective
Continued on page 2.
Knowledge Management, continued
decision making in a less stressful environment. With
the practice of Knowledge Management in the health
care sector, the following benefits may be possible:
1.)Avoidance of costly mistakes which have long
term implication for the patient/family, the
caregiver and the organization
2.)The sharing of best practices has proven to save
millions in the global corporate world and there
is nothing to suggest it would not do the same in
the healthcare environment
3.)Facilitating Team function and reducing work
stress through Collaboration and support
4.)KM translates to improving the knowledge work
processes; in health care that means: using
resources efficiently; ensuring care is timely,
accessible and current; and evaluating outcomes
5.)The promotion of successful innovation
As the clinical integration of our two health
systems accelerates and as the previously identified
synergies are more actively pursued, KM must
be considered in the process. Any organization,
especially larger ones, must understand that
in dollar costs, their employee’s knowledge is
the organization’s greatest asset and return on
As the two organizations continue their
corporate and clinical integration, Knowledge
Management should play a dynamic and important
role. Remember, KM is about all you know and
is an organization’s greatest asset and return on
Understanding who your employees are and what
they know are
essential assets
of any health care
organization. In
fact, Knowledge
Management is
20% information
technology and
80% people.
For KM to be
a successful
component in
our two health
care delivery
systems, individual
assets need to be
collectively and
managed. This may not be easy, but it is essential.
The MDS of both RGH and Unity are committed
to this concept and have encouraged the
administration to communicate often, openly and
timely in this regard. With this in mind, the MDS
Leadership encourages its membership to make their
expertise known and take positive actions on their
behalf in this period of rapid change.
The MDS of both
RGH and Unity
are committed to
this concept and
have encouraged
the administration
to communicate
often, openly and
1.Barth, S. Defining knowledge management. [Cited 2002 Jun
19]. Available from: URL: www.destinationKM
2.MoreOB.com. Knowledge Management
New Associate Medical Director for
RGH Adult ED
Dr. Zafar Shamoon is
the new Associate Medical
Director for the Adult
Emergency Services for
Rochester General Hospital.
He focuses on ensuring there
is an integrated care team to
provide rapid, high quality
care to our patients’ bedside.
In addition to working at
Rochester Regional Health
Dr. Zafar Shamoon
System since 2008, he
previously worked as an Attending at Independent
Emergency Physicians, P.C. in Detroit, Michigan.
Dr. Shamoon did his Undergrad and Medical school
at Michigan State University, and his ER Residency
in Detroit, MI. Dr. Shamoon is Board certified and
a fellow of the College of Emergency Medicine.
Dr. Shamoon’s greatest strengths are his care
and compassion for the community in which he
serves, as well as his ability to empower those
around him.
Rochester General Hospital Medical and Dental Staff FORUM
Performance Excellence Awards
Robert Mayo, MD, Chief Medical Officer, Executive Vice President, RRHS
I am proud to share an impressive set of accolades
our health system and team members recently
received that certainly attest to the talents of our
people and our ongoing commitment to live our
mission and values.
Healthcare Team Excellence -
The Greater Rochester Quality Council (GRQC),
a Rochester Business Alliance affiliate, presented
its 2014 GRQC Performance Excellence Awards
on October 7. Among 10 local organizations
recognized for excellence, we received three
prominent awards:
Healthcare Team Excellence ‐
Healthcare Team Excellence ‐
Clostridium difficile Reduction RGH ‐ Emergency Department RGH ‐ Cardiothoracic Surgery
Safety Hotline Project
With a goal of reducing blood
The Clostridium difficile Reduction
Project, led by a collaborative
team from Rochester General
Hospital, Unity Hospital, Excellus
BlueCross BlueShield, Highland
Hospital, Strong Memorial
Hospital and URMC’s Center for
Community Health, was honored
for exhibiting excellent teamwork
and achievement of the following
superior results across multiple
organizations to address C.
• Decrease in the rate of health
care facility acquired C. difficile
• Avoidance of extended
hospital stays for approximately
65 patients
• Significant estimated cost
savings of up to $2.2 million
This award recognized a
collaborative effort to improve
patient safety that embraced the
philosophy of “do no harm” by
designing an efficient process for
reporting and following up on
safety events in the Emergency
Department with the following
• 125 percent increase in the
number of Medical Staff who
participated in event reporting—
an accomplishment that also
received national recognition this
summer for innovation and impact
• Subsequent and measurable
improvements in patient
safety, job satisfaction, working
conditions and perception of
transfusions to improve patient
safety outcomes even further
than the already wellperforming
benchmark, the Cardiothoracic
Surgery team was recognized for
the following exceptional results:
• 22 percent decrease in blood
utilization from 2012 to 2013
• More than 50% reduction in
• Cost savings of more than
$120,000 annually
Congratulations to all the team members who contributed to the outstanding outcomes that
resulted in these significant awards. Your hard work, your passion for excellence and your
commitment to serving our patients is deeply appreciated by your colleagues and our community.
2015 quarterly staff meetings
March 20, June 19, September 18, December 18
7:30 – 9:00 am • Twig
Advance Practice Provider (APP) Activity
Margaret M Ecklund, NP (Rochester General/Senior Services), [email protected]
The local health care community is using the term
APP to encompass the group of providers including
Nurse Practitioners, Physician Assistants, Certified
Nurse Midwives, and Certified Registered Nurse
Anesthetists. Within RRHS, we have approximately
600 APP providers caring for our patients in
many settings and roles. We have had presence
on committees and the medical/dental board at
RGH over past years. The merger has created an
opportunity to learn more about each other and
explore synergistic opportunities.
We met on Sept 3 with key leaders from RGH
(Derek tenHoopen, Rob Mayo, Cheryl Sheridan),
with leaders from Unity (Dustin Riccio) to confirm
the support for direction and organization effort. A
steering team is currently working to include RGH
legacy, Unity legacy and Newark Wayne APPs in
developing a formal structure to present to the
Medical Dental Staff and hospital leadership. This is
a desirable window of time for APP’s to determine
where we as a group of providers would like to be
Considering the mission of RRHS, the APP
steering group will:
• Formalize a committee structure to have
representation and voice in key clinical decisions
• Develop a centralized method of communication
with all RRHS APP’s about news/updates/
concerns. Suggest a creation of an APP
website or weblink on RRHS main webpage for
• Form an advisory group to review the elements
of the Nurse Practitioner Modernization Act that
goes in effect January 2015. Nursing leaders will
coordinate this with Medical Staff leadership
• Develop and test an Onboarding / Mentoring
plan for new APPs in the system
• Keeping an organized list of all APP’s who
are involved on committee/boards. This will
help us determine where there is a gap in APP
Steering group members include: Margaret
Ecklund, NP, James Sutton, PA, John Caven, PA,
Heather Cook-Smith, NP, Julie Albert, NP, Alycia
Strobert, PA, Traci Salter, NP, Selma Mujezinovic, NP,
David Perry, PA, Tia DeRosa, NP, Michelle Storm,
PA, Marcy Soprano, NP, Regina LoMaglio, NP, Beth
Kenyon, PA, Sandy Visconti, PA. There are other
APPs who have expressed interest but were unable
to attend our recent meetings. We want to be as
inclusive as possible to interested APP’s. Our goal
is to have a diverse and well rounded APP steering
There is a great deal of energy and talent within
the diversity of the APP group across the system,
and we look forward to our enhanced partnership
with physician leadership and RRHS administration in
delivery of great patient care!
Every year, during the month of November, a week
has been designated by the American Academy of
Nurse Practitioners as National Nurse Practitioner
Week in celebration of the knowledge, skills and
professionalism of this group of advanced practice
nurses. This year it is November 9 - November 15.
In 1965, Denver Colorado graduated the first
class of Nurse Practitioners. The designated role of
these specially trained nurses was to take care of
the health care needs of a pediatric population that
was not being served by the current health care
providers of the times.
Years later the profession has grown beyond
hopes. There are currently over 192,000 nurse
practitioners in the United States and 173 here
at RGH. They now come in many specialties and
practice in many different
Rochester General Hospital Medical and Dental Staff FORUM
CDI Corner
How to Avoid a Query
By Kathy Agan, RHIT and Jamie Clark, RN
CHF - Include type and acuity of CHF. Such as: Systolic, Diastolic,
or combined Systolic and Diastolic and Acute, Chronic, Acute on
Chronic, Compensated, Decompensated.
Anemia - Include type: Anemia of Chronic disease (include chronic
disease. eg: CKD, cancer, etc.), Acute blood loss anemia, Chronic
blood loss anemia, post-surgical blood loss anemia, iron deficiency,
Renal Function - Acute VS Chronic:
• CKD - Include stage if CKD: 1, 2, 3, 4, 5 or ESRD
• Acute - Use terms such as: ARF, AKI, ATN, AIN
Respiratory Failure - Include acuity: Acute, Chronic, or Acute
on Chronic. Also include: Respiratory acidosis and/ or alkalosis.
Avoid terms “insufficiency” or hypoxic” because considered vague
Pneumonia - Include type of PNA: Aspiration, Gram-negative, Grampositive, fungal, bacterial (include bacteria suspected). Avoid terms
like CAP, HAP, HCAP, Atypical, and Multifocal because considered
vague terminology.
Urosepsis - (Avoid using this term). Specifiy whether this means
simple UTI or if patient has sepsis from a urinary source infection.
Malnutrition - Include severity and type: Mild, Moderate, or Severe
and protein-Calorie, Protein only, or Calorie only.
Ulcer - Include type of ulcer. Such as: Decubitus, Diabetic, Vascular,
Neuropathic, other. Include site(s) of ulcer(s) was present on
admission. Decubitus: include stage
Altered Mental Status - Include further specificity. Such as
Delirium due to infection, medication or disease process such as
Dementia, Dementia with Behavioral disturbance, Encephalopathy
(Metabolic, Hepatic, Septic, etc), adverse effect of medication.
Diabetes - Include conditions associated with diabetes. Such as:
Diabetic PVD, Diabetic Nephropathy, Diabetic gangrene, Diabetic
Ulcers (include if from diabetic neuropathy or diabetic PVD),
Diabetic gastroparesis.
Present on admission or Hospital Acquired - Include if a condition
was likely present at the time of admission. Such as: Sepsis, Foley
associated UTI, Pneumonia, Line Sepsis.
Sharp Debridement - Include further specificity of the type of
debridement and deepest layer of tissue debrided. Such as:
Excisional or non-excisional. Depth: Skin, subcutaneous, Soft
tissue, Muscle, Bone.
Lab and Imaging findings - Include any diagnosis that correlates
with lab and imaging findings based on your clinical opinion.
Link cause and effect - of conditions named as a diagnosis to
devices, organism, late effect, or other diagnosis you suspect as
underlying cause.
Symptom as diagnosis - Include the underlying cause of the
symptom. Probable, likely, or suspected are acceptable to use for
hospital inpatient billing.
The CDI team can be reached at 922-3721 for any
questions, or inperson on the hospital units, or in the CDI
office at B6006.
Congratulations to Dr. Nejmudin Kemal who was chosen
by CDI as the October “Documenter of the Month”!
National Medical Staff
Services Awareness
Week, November 2 - 8
In 1992, The United States Congress and President
George Bush issued a proclamation designating the
first week of November as “National Medical Staff
Services Awareness Week”.
When you go to the hospital seeking medical
care, how do you know that the Medical & Dental
Staff Members are properly trained, licensed
and qualified to take care of your patients? The
professionals working in the Medical Staff Office
investigate every practitioner who applies for
privileges to practice medicine at RGH. While the
department may not be involved in the “hands
on” care of patients, we are responsible for the
physicians’ hands that care for our patients.
We are dedicated professionals on the
frontline of physician advocacy. We work with the
Medical & Dental Staff leadership and Clinical
Department leadership to assure that only
applicants whose history can be accounted for,
are presented for membership consideration.
Through both the application process and the
reappointment process the Medical Staff Office
professionals secure information to assist the
clinical leadership while making decisions on
continued membership. Our actions assist the
hospital by assuring protection from incompetent,
troubled and impaired health care professionals.
We are trained to identify problematic applications
and reappointment documentation.
In addition, we are responsible for
communicating services to the 1471 members
of the RGH MDS, through meetings, mailings,
newsletters, directories etc. – all while maintaining
the highest level of customer service that
regulations allow. We also complete the initial
appointment and reappointment for the MDS of
Newark Wayne Community Hospital and Clifton
Springs Hospital.
The dedicated members of your RGH Medical
Staff Office have over 60 years dedicated to this
profession and are very grateful to be working
with the wonderful Medical & Dental Staff
Members of RGH. They are: Mary Lou McKeown,
Karen Curtis, Barbara Kahle, CPCS, Shelly Nyiri
Changes to your RGH Directory
For those of you who have access to the RGHS portal, don’t forget the on-line directory under Depts and Medical & Dental Staff. For those
of you who do not have access to the portal, there is a monthly excel directory available for you upon request. Contact Mary Lou McKeown
at 922-4259 or [email protected]
RGH MDS Welcomes the Following New Members
Syed Ali, MD, Dept of Neurology, 1425 Portland Ave
#220, Rochester, NY 14621, 585- 922-4227
Mohammad Azad, MD, Dept. of Med./Hospitalist,
1425 Portland Ave #287, Rochester, NY 14621, 585922-5067
Jayashri Bhaskar, MD, Dept. of Med./Pulmonary
Disease, 1425 Portland Ave #202, Rochester, NY
14621, 585-922-4409
Luanne Bianchi, RPA-C, Dept. of Emerg. Med./
Observation Unit, 1425 Portland Ave, Rochester, NY
14621, 585-922-9080
Justin Rymanowski, MD, Dept. of Neurology
1312 Driving Park Ave, Newark, NY 14513,
Kendra Shelters, RPA –C, Dept. of Surgery/Urology
1425 Portland Ave, 4500 Nursing, Rocehster, NY
14621, 585-922-4505
Adnan Siddiqui, MD, Dept. of Surg./Neurological
Surg., 100 High St B4, Buffalo, NY 14203,
Kenneth Snyder, MD, Dept. of Surg./Neruological
Surg., 100 High St B4, Buffalo, NY 14203, 716-218-1000
Aknur Butala, MD, Dept. of Neurology, 1425 Portland
Ave #220, Rochester, NY 14621, 585-922-4227
Julana Spaulding, CNM, Dept. of Ob/Gyn, 1415
Portland Ave #400, Rochester, NY, 14621, 585-922-4200
Shebene Chacko, MD, Dept of Med./Hospitalist
1425 Portland Ave #287, Rochester, NY 14621
Susan Szczepanski, NP, Dept. of Medicne/Int.Med.
1425 Portpand Ave #340, Rochester, NY 14621
Erdal Erturk, MD, Dept. of Surgery/Urological Surg.
601 Elmwood Ave #656, Rochester, NY 14642
Magdalena Szklarska-Imiolek, MD, Dept. of Psychiatry,
1425 Portland Ave G1, Rochester, NY 14621,
Juan Godinez, MD, Dept. of Radiation Oncology
1425 Portland Ave #223, Rochester, NY 14621
Eugene Tolomeo, MD, Dept. of Neurology, 1312
Driving Park Ave, Newark, NY 14513, 315-331-0806
Judy Guarino, CRNA, Dept. of Anesthesia, 1425
Portland Ave #282, Rochester, NY 14621, 585-922-4159
Matthew Turner, MD, Dept. of Pathology & Lab Med.,
1425 Portland Ave #400, Rochester, NY 14621,
Soufiane Khelil, MD, Dept. of Med./Hospitalist
1425 Portland Ave #282, Rochester, NY 14621
Kathleen VanderBrook, NP, Dept. of Surg./Vascular
Surg., 4 Coulter Rd #1760, Clifton Springs, NY 14432,
Mohamad Mahmoud, MD, Obstetrics & Gynecology
222 Alexander St #1100, Rochester, NY 14607
Joshua Weitz, MD, Dept. of Med. - Allergy/
Immunology/Rheumatology, 100 White Spruce Blvd,
Rochester, NY 14623, 716-272-0700
Jeanne O’Brien, MD,, Dept. of Surg./Urological Surg.
2400 S. Clinton Ave Bldg H 150 Rochester, NY 14642,
Brian Wood, MD, Dept. of Emergency Med., 1425
Portland Ave, Rochester, NY 14621, 585-922-5850
Prathima Pangulur, MD, Dept. of Med./Hospitalist
1425 Portland Ave #287, Rochester, NY 14621
Lisa Reno, NP, Dept. of Med./Endocrinology
224 Alexander St #200, Rochester, NY 14607
Guan Wu, MD, Dept. of Surgery/Urological Surgery
601 Elmwood Ave, Box 656, Rochester, NY 14642
Sandy Kalena Sachiko Perry, MD, 43 Willow Pond Way,
#200 Penfield, NY 14526, Phone (585)377-5420,
Fax: (585)377-3690
Directory Changes: Change to inactive
Kami Anderson, CRNA, Dept. of Anesthesiology
Linda Kovac-Tantalo, NP, Dept. of Psychiatry
Alice Loveys, MD, Dept. of Pediatrics
Roxanne Lowenguth, DDS, Dept. of Dentistry
John Marquardt, MD, Dept. of Orthopaedic Surgery
Olga Selioutski, DO, Dept. of Neurology
George Segel, MD, Dept. of Pediatrics
Kathy Taylor, RPA-C, Dept. of Medicine/Internal Medicine
Rochester General Hospital Medical and Dental Staff FORUM
GRIPA’s Population
GRIPA now has over 167,000
patients included in its
population health program!
This is a staggering number of
individuals and represents a
significant population within our
community. This article breaks
down the total population in several
different ways and addresses the
significant opportunity we have
to improve community health and
reduce the overall cost of care.
As a starting point, there are about:
• 135,000 Commercial members,
including children and
dependents of those with
employer sponsored health care
and other similar arrangements;
• 20,000 Medicare Advantage
members; and
• 12,000 fee-for-service traditional
Medicare beneficiaries through
the Medicare Shared Savings
Program Accountable Care
Organization (MSSP ACO).
All of these members became part
of the GRIPA population health
program through one of two ways:
1. by having healthcare insurance
with a payor with whom GRIPA
has a contract (i.e., Excellus
BCBS, Wellcare, Centers for
Medicare & Medicaid Services
{CMS}) and seeing a GRIPA
physician for primary care
services; or,
2. working as an employee at one
of the companies with whom
GRIPA has an employer contract
(Monroe County, LiDestri Food
and Beverage, Rochester
Regional Health System). The
difference with GRIPA’s employer
contracted members is that those
members may not necessarily
be seeing a GRIPA Primary Care
There are about 120,000
Commercial members who see a
GRIPA physician for their primary
care services and an additional
15,000 members through the
employer contracts who do not see
a GRIPA Primary Care Physician.
Within this commercial population,
50,000 members are under the age
of 18.
From a clinical perspective, GRIPA
uses its robust data warehouse and
many data sources to compile the
most complete and comprehensive
health profile of these populations of
patients with the goal of providing
higher quality care at reduced cost.
Within the Commercial population,
there are about 9,600 members with
diabetes representing about 6.2% of
the population. Similarly, there are
about 3,200 members with Coronary
Artery Disease (CAD) comprising just
over 2% of the entire population.
And, lastly there are over 25,300
members with hypertension, or
over 16% of the population. Using
GRIPA’s robust data warehouse,
we can determine the percentage
of these members with chronic
conditions having clinical indicators
outside of an acceptable range.
And, the good news is that our
network achieves among the best
scores as it relates to controlled
chronic conditions.
An even deeper dive into the data
shows opportunities to address
behavioral health issues as 15% of
the population has mental health
charges based on diagnoses coding
alone– which means the prevalence
is likely higher if pharmacy scripts
are also used to identify mental
health illness. And these patients
with behavioral health issues along
with one or more chronic conditions
have significantly higher medical
costs as compared to the average
Commercial member.
Taking all of this together – the
huge population of members, the
incredible data GRIPA aggregates
and analyzes, and the dedicated
and talented pool of physicians and
other providers, we have a unique
opportunity to assist those members
needing care and deliver the right
care to improve health and reduce
We at GRIPA look forward to
working with everyone in the Health
System to accomplish this mission.
RGH Atrium
October 6
6 am - 6 pm
Dialysis Seneca
October 15
Ridge Family Room
October 8
2 - 6 pm
October 10
7 am - 12 noon
October 11
7 am - 12 noon
October 11
4 - 8 pm
October 13
6 am - 6 pm
October 15
12 noon - 8:30 pm
October 16
6 am - 6 pm
October 17
12 - 8:30 pm
October 19
7 am - 12 noon
October 19
4 - 8 pm
October 16
12:30 - 3 pm
Bay Creek Dialysis
Conf. Room
Health Netowrk
GMHC Room A112
October 28
12:30 - 3:30 pm
RMHC Room 22B
October 22
8:30 - 11:30 am
12:30 - 3 pm
2066 Hudson Ave,
Conf. Room
October 6
12 - 4 pm
490 Ridge Rd E,
PACE Boardroom
October 8
8 am - 12 noon
Blossom Rd, TBD
November 3
12 - 4 pm
French Rd, TBD
November 3
7 - 11 am
Hill Haven
Dietary Office
October 6
7 - 9:30 am
October 15
2:30 - 4:30 pm
October 20
7 - 9:30 am
October 9
3 - 7 pm
October 23
11 am - 1 pm
November 11
6 - 9 am
October 23
8:30 am - 4 pm
November 12
8:30 am - 4 pm
NWCH Café 1
Riedman Campus
West Conf. Room
You can also get a vaccine at TEAM MEMBER HEALTH SERVICES
during regular weekday hours or anytime in many CLINICAL UNITS.
RGHS 9-2014
Declination or Medical Waiver
I acknowledge that I am aware of the following facts:
¥ Influenza is a serious respiratory disease that kills thousands of people in the United States
each year.
¥ Influenza vaccination is recommended for me and all other health care workers to protect this facility’s
patients from influenza, its complications and death.
¥ If I contract influenza, I can spread the virus for 24 hours before the influenza symptoms appear.
Knowing these facts, I choose to:
( ) Decline the vaccine.
( ) I have been advised by my physician not to receive the vaccine due to an allergy or medical condition;
therefore I have a Medical Waiver.
Please sign below
Print Name: _________________________________________________RRHS Team Member ID # (employees only): _______________
Affiliate Name: ____________________________________________________________________________________________________
Signature: __________________________________________________________________ Date of Vaccine: ______________________
Address: ___________________________________________________________________ Todays Date: _________________________
Please check those that apply
( ) RRHS Team Member
__ Legacy RGHS
__ Legacy Unity
( ) RGH or NWCH Medical and Dental Staff
( ) Volunteer
( ) Student
( ) Contractor
RRHS Team Members, please provide completed form(s) to your direct supervisor.
RGH Medical & Dental Staff, please fax this completed form to MSO at 585-922-4778.
NWCH Medical & Dental Staff, please fax this completed form to MSO at 315-332-2371.
Medical & Dental Staff – If you are a member of both RGH & NWCH institutions, you only need to send to one of them.
Leader/Administrator please complete the following actions to process this form:
( ) Record the individual’s declination/waiver status in the RRHS online vaccine tracking system
(available from the RRHS Portal home page).
( ) Send this form to Team Member Health Services at RGH
(1425 Portland Avenue) or by fax at 585-922-4790.
Off-Site Confirmation Form
( )
I have received the influenza vaccine for the 2014-15 flu season and have attached
documentation of the vaccine including:
– Name of provider
– Address of provider
Please sign below
Print Name: _________________________________________________RRHS Team Member ID # (employees only): _______________
Affiliate Name: ____________________________________________________________________________________________________
Signature: __________________________________________________________________ Date of Vaccine: ______________________
Address: ___________________________________________________________________ Todays Date: _________________________
Please check those that apply
( ) RRHS Team Member
__ Legacy RGHS
__ Legacy Unity
( ) RGH or NWCH Medical and Dental Staff
( ) Volunteer
( ) Student
( ) Contractor
RRHS Team Members, please provide completed form(s) to your direct supervisor.
RGH Medical & Dental Staff, please fax this completed form and vaccination documentation to MSO at 585-922-4778.
NWCH Medical & Dental Staff, please fax this completed form and vaccination documentation to MSO at 315-332-2371.
Medical & Dental Staff – If you are a member of both RGH & NWCH institutions, you only need to send to one of them.
Leader/Administrator please complete the following actions to process this form:
( ) Record the individual’s vaccine status in the RRHS online vaccine tracking system
(available from the RRHS Portal home page).
( ) Send this form and any required documentation to Team Member Health Services at RGH
(1425 Portland Avenue) or by fax at 585-922-4790.