FROM: Practice Name: Address: City: State: ZIP: Instructions: Please answer each question and subquestion by filling in the appropriate circle.Then, based on your practice location, mail the completed attestation and any related documentation to:
AMERICANS WITH DISABILITIES ACT (ADA) ATTESTATION FROM: Practice Name: Address: City: State: ZIP: Instructions: Please answer each question and subquestion by filling in the appropriate circle. Then, based on your practice location, mail the completed attestation and any related documentation to: New York City, Nassau, Suffolk: EmblemHealth 55 Water Street New York, NY 10041 Attn: Physician Contracting, 7th Floor All Other Counties in New York: EmblemHealth 5015 Campuswood Drive East Syracuse, NY 13057 Attn: Physician Contracting If you are completing this form on behalf of a practice, please attach a listing of practitioners at your office. If your practice has more than one location, please complete a form for each location and attach a listing of practitioners for each location. Once submitted, please notify EmblemHealth within 10 business days of any change to your answers below. Additional forms can be downloaded from the "Join Our Networks" page at www.emblemhealth.com. Note: If you do not see patients at the address above (e.g., you're an inpatient provider only or administrative only), please answer N/A here, sign the form and mail it back. N/A 1. D oes the office have at least one wheelchair-accessible path from an entrance to an exam room? 2. Are examination tables and all equipment accessible to people with disabilities? 3. If parking is provided, are there spaces reserved for people with disabilities and pedestrian ramps at sidewalks and drop-offs? 4. If parking is provided, are there an adequate number (see below) of accessible parking spaces (8 feet wide for a car and 5-foot access aisle)? Total spaces Accessible spaces 1-25 1 26-50 2 51-75 3 76-100 4 5. a. F or a provider with a disability-accessible parking space, is there a path of travel from the disability-accessible parking space to the facility entrance that does not require the use of stairs? b. Is the path of travel stable, firm and slip resistant? c. Except for curb cuts, is the path at least 36 inches wide? 6. a. Is there a method for persons using wheelchairs or requiring other mobility assistance to enter as freely as everyone else? b. Is that route of travel safe and accessible for everyone, including people with disabilities? 7. Does the main exterior entrance door used by persons with mobility disabilities to access public spaces meet the following: a. 32 inches clear opening. b. 18 inches of clear wall space on the pull side of the door, next to the handle. c. T he threshold edge is no greater than ¼-inch high; if beveled, no greater than ¾-inches high. d. The door handle is no higher than 48-inches high and can be operated with a closed fist. Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A (Continued) Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_FRM_18881_ADA_Attestation 10/14 8. a. Are there ramps to permit access? If yes, complete the following four questions: Yes b. Are the slopes of the ramp accessible for wheelchair access? Yes c. Are the railings sturdy and high enough for wheelchair access? Yes d. Is the width between railings wide enough to accommodate a wheelchair? Yes e. Are the ramps nonslip and free from any obstruction (cracks)? Yes 9. If there are stairs at the main entrance, is there also a ramp or lift or is there an alternative Yes accessible entrance? 10. Do any inaccessible entrances have signs indicating the location of the nearest accessible entrance? Yes 11. Can the accessible entrance be used independently and without assistance? Yes 12. Are doormats ½-inch high or less with beveled or secured edges? Yes 13. Are waiting rooms and exam rooms accessible to people with disabilities? Yes 14. Does the layout of the interior of the building allow people with disabilities to obtain materials and services Yes without assistance? 15. Do the interior doors comply with the criteria set forth for exterior doors (see question 7)? Yes 16. Are the accessible routes to all public spaces in the facility 31-inches wide? Yes 17. Is there a 5-foot circle or a T-shaped space for a disabled person using a wheelchair to reverse Yes direction in public areas where services are rendered? 18. Are all buttons or other controls in the hallway no higher than 42 inches? Yes 19. Do elevators in the facility meet the following standards: a. There are raised and Braille signs on both door jambs on every floor. Yes b. The controls inside the cab have raised and Braille lettering. Yes c. The call buttons in the hallway are not higher than 42 inches. Yes 20. Are sign language interpreters and other auxiliary aids and services provided in appropriate circumstances? Yes 21. Is the public lavatory wheelchair-accessible? Yes 22. With respect to the public restroom, do the accessible route, the exterior door and the interior stall doors Yes comply with standards set forth for exterior doors (see question 7)? 23. Is there at least one wheelchair-accessible stall in the public restroom that has an area of at least Yes 5 feet by 5 feet clear of the door swing or is there at least one stall that is less accessible but provides greater access than a typical stall (either 36 by 69 inches or 48 by 69 inches)? 24. In the accessible stall of the public restroom, are there grab bars behind and on the side wall nearest Yes the toilet? 25. Is there one lavatory in the public restroom that meets the following standards: a. 30-inches wide by 48 inches; deep bar space in front. Yes b. A maximum of 19 inches of the required depth may be under the lavatory. Yes c. The lavatory rim is no higher than 34 inches. Yes d. There are at least 29 inches from the floor to the bottom of the lavatory apron. Yes e. The faucet can be operated with a closed fist. Yes f. The soap dispenser and hand dryers are within reach and usable with one closed fist. Yes g. T he mirror is mounted with the bottom edge of the reflecting surface 40 inches from the Yes floor or lower. No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A No N/A I hereby attest that I am a provider that occupies a physical site at which participants might possibly be physically present and that the answers provided are accurate. Or, I do hereby attest that I hold the authority to make these attestations. Name: Date: Signature:Adobe InDesign CS6 (Macintosh) Adobe PDF Library 10.0.1