To begin the medical second opinion process, please complete the following steps:

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1 The purpose of the Medical Second Opinion (MSO) program of Johns Hopkins Medicine International is to provide information to the patient or the local treating physician so that an informed decision can be made in managing the patient s healthcare needs. This program aims to provide an alternative to traveling at this time to the United States for care. However, should the patient travel to Johns Hopkins for care in the future, Johns Hopkins Medicine International will make all necessary arrangements. To begin the medical second opinion process, please complete the following steps: 1. Complete MSO packet (which includes: Patient Information sheet, Credit Card Authorization form, Telemedicine Consent form and Authorization for Release of Health Information.) 2. Gather the most recent typed medical records in English. If needed the MSO program can arrange for translations of medical records for an additional fee. A. Radiology Radiology images and corresponding report(s) are required for most clinical specialties. Images sent on CD should be in DICOM format. If possible please send copies, not originals, of all documents and images. If sending films, please let us know if you need them to be returned after the MSO is complete. B. Pathology (optional) The patient has the option of having his or her pathology specimen reviewed by a Johns Hopkins pathologist. The review of stained slides is included in the cost of a complex consultation. Unstained slides and/or blocks require an additional charge of US$ In order to avoid a delay at U.S. customs, please write the following on the pathology slide/block commercial invoice: Slides and/or paraffin blocks (and corresponding pathology reports) of noninfectious and non-contagious human tissue taken from the (organ/tissue) which are fixed and/or preserved in paraffin. This specimen has never been cultured. It is for review by the Department of Pathology at Johns Hopkins Hospital, Baltimore, MD. The value is US$1.00. Pathology reports should be sent along with the pathology slides or paraffin blocks. Each slide or block should have a corresponding number on the report. 3. Forward via fax, international courier, or the completed MSO packet and medical records to: Johns Hopkins Medicine International Medical Second Opinion (MSO Program) 5801 Smith Ave. McAuley Hall, Suite: 305 Baltimore, MD Phone#: Fax #: medicalsecondopinion@jhmi.edu jhintl.net

2 Once the packet is received: 1. We will review the information and charge the credit card noted on the Credit Card Authorization Form. The medical second opinion process will not begin until our office confirms that the information received is adequate and complete, and that no further information is forthcoming. The medical second opinion consult will be based on the information that is sent, so it is essential that the documents are accurate and as up-to-date as possible. 2. We will regularly update you on the progress of the medical second opinion. Please note that our hours of operation are Monday-Friday, 7:30am-5:00pm Eastern Time (EST). During these hours, we will respond promptly to any questions or concerns. 3. If we receive additional medical records and/or questions after the physician has started the review, an extra charge will apply. The review of additional information will depend on the discretion and willingness of the physician assigned to the case. 4. Upon completion of the medical second opinion, the patient s case will be closed. If the patient would like to schedule an in-person consult with a Johns Hopkins physician, the case will be forwarded to Johns Hopkins Medicine International Patient Services, who can assist in this process. Please note that obtaining a Medical Second Opinion does not guarantee an in-person consult. 5. No medical information provided by the patients will be returned upon completion of the medical second opinion, unless specifically requested by the patient, in which case an additional processing fee of US$75 will be charged. After six months of inactivity, medical records will be appropriately discarded. The cost of this service is determined by the complexity of the case and the preferred format of the medical second opinion. The cost typically ranges from US$800 to US$1500. A more accurate estimate can be provided upon request. Please note: This cost includes the opinion of one physician. Any additional physician s opinions will result in additional charges. We look forward to helping you obtain the best medical expertise here at Johns Hopkins.

3 CHECKLIST: The following list of items is needed to provide you with the best assessment and recommendation: Required Forms: Telemedicine Consent Form Patient Information Sheet Credit Card Authorization Form Authorization for Release of Health Information Copy of Passport Medical Information: Recent Medical Report (required for all requests) Lab Test Results Radiology (X-Ray, CT, MRI) Films and all corresponding Reports Pathology Slides and corresponding reports (with serial numbers) Other

4 TELEMEDICINE CONSENT FORM I have requested that Johns Hopkins Medicine International, LLC ("JHI") arrange a telemedical consult for me regarding the condition described below with a physician employed by The Johns Hopkins University ("JHU"). Via this consult, JHI will provide me with the conclusions of the JHU physician. The JHU physician will reach those conclusions based solely on the information provided by me or my physician to JHI. Neither JHI, JHU nor any of their affiliates (collectively, the "Hopkins Parties") shall have any liability or responsibility for the accuracy or completeness of that information or for any errors in its transmission. By providing the JHU physician s conclusions, the Hopkins Parties do not assume any continuing responsibility for my medical care or treatment. In addition, I recognize that, without a complete in-person physical examination, the JHU physician will be limited in his or her ability to correctly assess or diagnose my condition and recommend treatment. Although the Hopkins Parties have no obligation to obtain additional medical records or other information regarding my condition, I authorize my physician and any other person or entity to release any information pertaining to my health including health history, present complaints and laboratory and diagnostic data to any of the Hopkins Parties. The Hopkins Parties are authorized, at their election, to obtain any of such records and information. For myself and my heirs, personal representatives, administrators, successors and assigns, I irrevocably release the Hopkins Parties and their insurers, officers, directors and employees from any and all known or unknown, foreseen or unforeseen, claims, actions or damages arising in connection with the consult or JHU physician s conclusions. Patient s Current Diagnosis:. Patient Name (please print) Patient Signature Date Witness Signature Date

5 DATE: Month/Day/Year TO: JOHNS HOPKINS MEDICINE INTERNATIONAL Medical Second Opinion (MSO) Program FROM: PATIENT / PHYSICIAN / CONTACT PERSON (Please Circle One) PHONE #: FAX#: #: *PATIENT DIAGNOSIS: PATIENT DEMOGRAPHIC INFORMATION *Family Name: * Given Name: *Sex: Female Male *Date of Birth: Month/Day/Year *Race: Asian Black Hispanic White Other *Address: *Phone #: *Father s Full Name: *Mother s Full Maiden Name: MY QUESTIONS FOR JHM PHYSICIAN REGARDING CURRENT CONDITION (If more space is needed, please attach an additional page to this packet.) PLEASE NOTE THAT ALL SECTIONS OF THIS FORM MUST BE COMPLETED.

6 CREDIT CARD AUTHORIZATION FORM As per The Health Information Privacy and Portability Act (HIPAA), the following information is strictly confidential. I authorize Johns Hopkins Medicine International and affiliated providers to charge this credit card for the cost of a medical second opinion no greater than $1,500. I understand that this charge will be applied to the credit card provided upon receipt of this completed form. American Express MasterCard Visa Credit Card Number Expiration Date / Card Holder Name Card Holder Signature Patient Name

7 JOHNS HOPKINS INSTITUTIONS For addressograph plate AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION NOT TO BE USED IN CONNECTION WITH HEALTH INFORMATION FROM SUBSTANCE ABUSE TREATMENT OR MENTAL HEALTH PROGRAMS. All items on this authorization must be completed or the request will not be honored. Use "N/A" if not applicable. Patient Name: Address: (first) (m. initial) (last) (street address) (city) (state) (zip code) Medical Record #: Birth Date: For this authorization, My Health Information means: Abstract (discharge summary, operative notes, clinic notes, diagnostic testing) Billing Record Discussion with Healthcare Provider Other: For the date(s) of service from: to: [insert date(s) of service requested] I do do not want records received from other healthcare providers that are a part of my Johns Hopkins records included in this request. (If neither box is checked those records will be provided if the request is for all records.) I authorize _ Johns Hopkins Medicine International to provide My Health Information to me to another person or entity Johns Hopkins physicians for Remote Medical Second Opinion. My Health Information should be faxed to (Note: we cannot call before faxing) OR sent to: [insert fax number] [insert contact name at entity, if applicable] [insert street address] [insert city, state and zip code]

8 I understand there may be a charge for copying and handling my request. I understand that all fees will be in compliance with applicable Maryland guidelines. By signing this authorization, I agree to pay these fees at the time this request is made. I understand that: This authorization is voluntary. My treatment will not be impacted, no matter if I sign this authorization or not. If I do not sign this authorization, Johns Hopkins will not disclose My Health Information as requested. I will receive a copy of this authorization upon signature. This authorization is valid for one year from date signed, unless I revoke this authorization or unless an earlier date is specified here:. I may revoke this authorization by mailing or faxing my written request along with a copy of the original authorization to the clinic or department where my authorization was made or given. Once My Health Information is disclosed as requested, it may no longer be protected by federal and state privacy laws, and could be re-disclosed by the person(s) receiving it. The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse, etc. Signature of Patient Date: only: (Required) If you are NOT the patient but are signing on behalf of the patient complete the following: I,, (print your name) confirm that I am the legally appointed representative for the patient and I have CIRCLED my relationship to the patient below: Parent with Parental Rights Registered Kinship Care Relative Court Appointed Guardian Legally Appointed Healthcare Agent Medical Power of Attorney Power of Attorney with Right to See Medical Records Surrogate Decision Maker Court Appointed Personal Representative of Deceased Representative s Signature: Date: (Required) Address: Phone: You must attach proof of your authority to act on behalf of the patient as circled above (other than parent).