Re: outpatient referrals by nonstaff MDs

[Guest guest]

Historically, hospital systems like to keep the gravy train going within their

own system. From acute care to rehab to home health to outpatient services, the

unwritten rule is to keep the patient within the hospital system, not for

continuity of care as much as increased profits.

Hospital systems are jumping on the ACO bandwagon and are buying out physician

practices within surrounding communities.

Generally speaking, hospital systems do have outpatient physical therapy

satellites in communities. This means there isn't inconvenience to patients in

various communities surrounding the large hospital headquarters.

Reality... hospital systems have physicians who use hospital referral pads when

making referrals. People who have this piece of paper in their hot little hands

contact or choose from services on that sheet of paper. The choices on that

sheet of paper only direct the hospital patients to hospital locations for

services. It is completely unheard of for a hospital system to provide options

outside of the system. It is also unheard of for that piece of paper to

communicate freedom of choice for services.

Hospital systems have monopolized this way for years without divulging facts &

the freedom of choice to patients within their system. Hospital systems have a

very large chunk of a population in any area who utilize services. Hospital

systems monitor referral patterns. Private practices and freedom of choice have

been ignored for years on this particular topic.

I'm not for more and more regulations. I think it creates increased cost to

verify medical staff privileges. Does this truly limit freedom of choice? Not

completely. Remember, patients have the freedom to choose and that freedom isn't

captured by any hospital system anyways because full disclosure doesn't occur in

the real world. It forces hospital systems to grant every physician within their

system medical staff privileges. Remember, the unwritten rule is to refer within

the system.

The only logical way to determine departmental impact of this - because really,

you are all talking money and the loss of revenue - is to dig into your

databases and analyze your top 25 referral sources. How many of those referral

sources are not already within the hospital system? And... from that, how many

of those currently within the hospital system do not have medical staff

privileges?

To understand the full " effect " of this, what's the data indicate?

And, for those of you in private practice. Now would be a nice time to question

your top referral sources and learn who has privileges where. You can educate

them on their options for where to refer for physical therapy services based on

this new regulation. If you happen to have referral sources without privileges

and you just happen to compete with a hospital system - especially a hospital

system that isn't a team player in the community, you could share a referral

source NPI number and contact your Medicare payer questioning if they have paid

for services at the hospital site.

Selena Horner, PT

ton, MI

>

> Good afternoon for those practicing in hospitals that see outpatients how is

the new CMS interpretations affecting you if the doctor is not on staff of the

hospital they can no longer refer to the hospital. I copied the language and

the link below it was effective November 18, 2011.

>

> http://www.cms.gov/transmittals/downloads/R72SOM.pdf

>

> §482.56( Standard: Delivery of Services

> Services must only be provided under the orders of a qualified and licensed

practitioner who is responsible for the care of the patient, acting within his

or her scope of practice under State law, and who is authorized by the

hospital's medical staff to order the services in accordance with hospital

policies and procedures and State laws.

> Interpretive Guidelines §482.56(

> Rehabilitation services must be ordered by a qualified and licensed

practitioner who is responsible for the care of the patient. The practitioner

must have medical staff privileges to write orders for these services.

Privileges must be granted in a manner consistent with the State's scope of

practice law, as well as with hospital policies and procedures governing

rehabilitation services developed by the medical staff and approved by the

governing body. Practitioners who may be granted privileges to order

rehabilitation services include physicians, and may also, in accordance with

hospital policy, be extended to Nurse Practitioners, Physicians' Assistants, and

Clinical Nurse Specialists as long as they meet the parameters of this

requirement. Although the following licensed professionals are also considered

" practitioners " in accordance with Section 1842((18)© of the Social Security

Act, they generally would not be considered responsible for the care of the

patient or qualified to order rehabilitation services: Certified registered

nurse anesthetist (Section 1861(bb)(2) of the Act); Certified nurse-midwife

(Section 1861(gg)(2) of the Act); Clinical social worker (Section 1861(hh)(1) of

the Act); Clinical psychologist (for purposes of Section 1861(ii) of the Act and

as defined at 42 CFR 410.71); or registered dietician or nutrition professional.

>

> L. , PT, DPT, MBA

> Director, Physical Rehabilitation Services

> East Orange General Hospital

> phone

> fax

> pager

> " An ounce of prevention is worth a pound of cure. "

>

>

>

>

________________________________________________________________________________\

________________

> IMPORTANT: This message contains confidential information and is intended

only for the individual(s) named.

> If you are not the named addressee, you are not authorized (either explicitly

or implicitly) to disseminate,

> distribute or copy this e-mail in any manner whatsoever. Please notify the

sender immediately by e-mail if you

> received this e-mail in error and delete this e-mail from your system.

Unintended transmission shall not

> constitute waiver of the attorney-client or any other applicable privilege.

E-mail transmission cannot be

> guaranteed to be secure or error-free as information could be intercepted,

corrupted, lost, destroyed, arrive

> late or incomplete, or contain viruses. The sender therefore does not accept

liability for any errors or omissions

> in the contents of this message, which arise as a result of e-mail

transmission.

>

[Guest guest]

I have owned a Private Practice and now I manage the Rehab Dept. of a large

hospital. Our hospital system does not require our employed physicians to refer

to the hospital's outpatient clinics. However, we do cultivate a culture around

easing the way of our patient's through our multiple layers of care. We compete

with private practices and physician owned practices just as you do. I am sure

that not all hospitals operate like we do. That said, it seems that many who

post on this list serve seem to be dividing our profession by labeling hospital

outpatient systems as the enemy. That is painful given that many hospital Rehab

Directors are quite active in the APTA, operate excellent practices that meet

Joint Commission requirements ( which are very stringent and cost a lot

resources to meet) and have to figure out ways to serve the uninsured. When I

was in private practice, I had access to many contracts that the hospital

systems in town could not get. In fact, the best contracts in town are not

available to my hospital system but are available to private practitioners.

This is just business. No one gets everything. Here in Oregon, our system is

going to be part of an ACO. I envision that we will need some help in treating

the extra 600,000 Oregonians that are going to become insured. Will the

reimbursement be good? I don't think so. Will we need to come up with a new

model to deliver care? I think so. Will that involve practices that are not a

part of our system? I think so. However, we will choose carefully. Our

average number of visits per patient is between 6 - 7. Our outcomes are great

and our patients are satisfied. So, we will want to partner with practices that

can match our outcomes and our average number of visits. I am hopeful that

there will be many colleagues who will want to work with us.

From: PTManager [mailto:PTManager ] On Behalf Of

selenahorner

Sent: Saturday, January 14, 2012 2:41 PM

To: PTManager

Subject: Re: outpatient referrals by nonstaff MDs

Historically, hospital systems like to keep the gravy train going within their

own system. From acute care to rehab to home health to outpatient services, the

unwritten rule is to keep the patient within the hospital system, not for

continuity of care as much as increased profits.

Hospital systems are jumping on the ACO bandwagon and are buying out physician

practices within surrounding communities.

Generally speaking, hospital systems do have outpatient physical therapy

satellites in communities. This means there isn't inconvenience to patients in

various communities surrounding the large hospital headquarters.

Reality... hospital systems have physicians who use hospital referral pads when

making referrals. People who have this piece of paper in their hot little hands

contact or choose from services on that sheet of paper. The choices on that

sheet of paper only direct the hospital patients to hospital locations for

services. It is completely unheard of for a hospital system to provide options

outside of the system. It is also unheard of for that piece of paper to

communicate freedom of choice for services.

Hospital systems have monopolized this way for years without divulging facts &

the freedom of choice to patients within their system. Hospital systems have a

very large chunk of a population in any area who utilize services. Hospital

systems monitor referral patterns. Private practices and freedom of choice have

been ignored for years on this particular topic.

I'm not for more and more regulations. I think it creates increased cost to

verify medical staff privileges. Does this truly limit freedom of choice? Not

completely. Remember, patients have the freedom to choose and that freedom isn't

captured by any hospital system anyways because full disclosure doesn't occur in

the real world. It forces hospital systems to grant every physician within their

system medical staff privileges. Remember, the unwritten rule is to refer within

the system.

The only logical way to determine departmental impact of this - because really,

you are all talking money and the loss of revenue - is to dig into your

databases and analyze your top 25 referral sources. How many of those referral

sources are not already within the hospital system? And... from that, how many

of those currently within the hospital system do not have medical staff

privileges?

To understand the full " effect " of this, what's the data indicate?

And, for those of you in private practice. Now would be a nice time to question

your top referral sources and learn who has privileges where. You can educate

them on their options for where to refer for physical therapy services based on

this new regulation. If you happen to have referral sources without privileges

and you just happen to compete with a hospital system - especially a hospital

system that isn't a team player in the community, you could share a referral

source NPI number and contact your Medicare payer questioning if they have paid

for services at the hospital site.

Selena Horner, PT

ton, MI

>

> Good afternoon for those practicing in hospitals that see outpatients how is

the new CMS interpretations affecting you if the doctor is not on staff of the

hospital they can no longer refer to the hospital. I copied the language and the

link below it was effective November 18, 2011.

>

> http://www.cms.gov/transmittals/downloads/R72SOM.pdf

>

> §482.56( Standard: Delivery of Services

> Services must only be provided under the orders of a qualified and licensed

practitioner who is responsible for the care of the patient, acting within his

or her scope of practice under State law, and who is authorized by the

hospital's medical staff to order the services in accordance with hospital

policies and procedures and State laws.

> Interpretive Guidelines §482.56(

> Rehabilitation services must be ordered by a qualified and licensed

practitioner who is responsible for the care of the patient. The practitioner

must have medical staff privileges to write orders for these services.

Privileges must be granted in a manner consistent with the State's scope of

practice law, as well as with hospital policies and procedures governing

rehabilitation services developed by the medical staff and approved by the

governing body. Practitioners who may be granted privileges to order

rehabilitation services include physicians, and may also, in accordance with

hospital policy, be extended to Nurse Practitioners, Physicians' Assistants, and

Clinical Nurse Specialists as long as they meet the parameters of this

requirement. Although the following licensed professionals are also considered

" practitioners " in accordance with Section 1842((18)© of the Social Security

Act, they generally would not be considered responsible for the care of the

patient or qualified to order rehabilitation services: Certified registered

nurse anesthetist (Section 1861(bb)(2) of the Act); Certified nurse-midwife

(Section 1861(gg)(2) of the Act); Clinical social worker (Section 1861(hh)(1) of

the Act); Clinical psychologist (for purposes of Section 1861(ii) of the Act and

as defined at 42 CFR 410.71); or registered dietician or nutrition professional.

>

> L. , PT, DPT, MBA

> Director, Physical Rehabilitation Services

> East Orange General Hospital

> phone

> fax

> pager

> " An ounce of prevention is worth a pound of cure. "

>

>

>

> __________________________________________________________

> IMPORTANT: This message contains confidential information and is intended only

for the individual(s) named.

> If you are not the named addressee, you are not authorized (either explicitly

or implicitly) to disseminate,

> distribute or copy this e-mail in any manner whatsoever. Please notify the

sender immediately by e-mail if you

> received this e-mail in error and delete this e-mail from your system.

Unintended transmission shall not

> constitute waiver of the attorney-client or any other applicable privilege.

E-mail transmission cannot be

> guaranteed to be secure or error-free as information could be intercepted,

corrupted, lost, destroyed, arrive

> late or incomplete, or contain viruses. The sender therefore does not accept

liability for any errors or omissions

> in the contents of this message, which arise as a result of e-mail

transmission.

>

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

[Guest guest]

I have owned a Private Practice and now I manage the Rehab Dept. of a large

hospital. Our hospital system does not require our employed physicians to refer

to the hospital's outpatient clinics. However, we do cultivate a culture around

easing the way of our patient's through our multiple layers of care. We compete

with private practices and physician owned practices just as you do. I am sure

that not all hospitals operate like we do. That said, it seems that many who

post on this list serve seem to be dividing our profession by labeling hospital

outpatient systems as the enemy. That is painful given that many hospital Rehab

Directors are quite active in the APTA, operate excellent practices that meet

Joint Commission requirements ( which are very stringent and cost a lot

resources to meet) and have to figure out ways to serve the uninsured. When I

was in private practice, I had access to many contracts that the hospital

systems in town could not get. In fact, the best contracts in town are not

available to my hospital system but are available to private practitioners.

This is just business. No one gets everything. Here in Oregon, our system is

going to be part of an ACO. I envision that we will need some help in treating

the extra 600,000 Oregonians that are going to become insured. Will the

reimbursement be good? I don't think so. Will we need to come up with a new

model to deliver care? I think so. Will that involve practices that are not a

part of our system? I think so. However, we will choose carefully. Our

average number of visits per patient is between 6 - 7. Our outcomes are great

and our patients are satisfied. So, we will want to partner with practices that

can match our outcomes and our average number of visits. I am hopeful that

there will be many colleagues who will want to work with us.

From: PTManager [mailto:PTManager ] On Behalf Of

selenahorner

Sent: Saturday, January 14, 2012 2:41 PM

To: PTManager

Subject: Re: outpatient referrals by nonstaff MDs

Historically, hospital systems like to keep the gravy train going within their

own system. From acute care to rehab to home health to outpatient services, the

unwritten rule is to keep the patient within the hospital system, not for

continuity of care as much as increased profits.

Hospital systems are jumping on the ACO bandwagon and are buying out physician

practices within surrounding communities.

Generally speaking, hospital systems do have outpatient physical therapy

satellites in communities. This means there isn't inconvenience to patients in

various communities surrounding the large hospital headquarters.

Reality... hospital systems have physicians who use hospital referral pads when

making referrals. People who have this piece of paper in their hot little hands

contact or choose from services on that sheet of paper. The choices on that

sheet of paper only direct the hospital patients to hospital locations for

services. It is completely unheard of for a hospital system to provide options

outside of the system. It is also unheard of for that piece of paper to

communicate freedom of choice for services.

Hospital systems have monopolized this way for years without divulging facts &

the freedom of choice to patients within their system. Hospital systems have a

very large chunk of a population in any area who utilize services. Hospital

systems monitor referral patterns. Private practices and freedom of choice have

been ignored for years on this particular topic.

I'm not for more and more regulations. I think it creates increased cost to

verify medical staff privileges. Does this truly limit freedom of choice? Not

completely. Remember, patients have the freedom to choose and that freedom isn't

captured by any hospital system anyways because full disclosure doesn't occur in

the real world. It forces hospital systems to grant every physician within their

system medical staff privileges. Remember, the unwritten rule is to refer within

the system.

The only logical way to determine departmental impact of this - because really,

you are all talking money and the loss of revenue - is to dig into your

databases and analyze your top 25 referral sources. How many of those referral

sources are not already within the hospital system? And... from that, how many

of those currently within the hospital system do not have medical staff

privileges?

To understand the full " effect " of this, what's the data indicate?

And, for those of you in private practice. Now would be a nice time to question

your top referral sources and learn who has privileges where. You can educate

them on their options for where to refer for physical therapy services based on

this new regulation. If you happen to have referral sources without privileges

and you just happen to compete with a hospital system - especially a hospital

system that isn't a team player in the community, you could share a referral

source NPI number and contact your Medicare payer questioning if they have paid

for services at the hospital site.

Selena Horner, PT

ton, MI

>

> Good afternoon for those practicing in hospitals that see outpatients how is

the new CMS interpretations affecting you if the doctor is not on staff of the

hospital they can no longer refer to the hospital. I copied the language and the

link below it was effective November 18, 2011.

>

> http://www.cms.gov/transmittals/downloads/R72SOM.pdf

>

> §482.56( Standard: Delivery of Services

> Services must only be provided under the orders of a qualified and licensed

practitioner who is responsible for the care of the patient, acting within his

or her scope of practice under State law, and who is authorized by the

hospital's medical staff to order the services in accordance with hospital

policies and procedures and State laws.

> Interpretive Guidelines §482.56(

> Rehabilitation services must be ordered by a qualified and licensed

practitioner who is responsible for the care of the patient. The practitioner

must have medical staff privileges to write orders for these services.

Privileges must be granted in a manner consistent with the State's scope of

practice law, as well as with hospital policies and procedures governing

rehabilitation services developed by the medical staff and approved by the

governing body. Practitioners who may be granted privileges to order

rehabilitation services include physicians, and may also, in accordance with

hospital policy, be extended to Nurse Practitioners, Physicians' Assistants, and

Clinical Nurse Specialists as long as they meet the parameters of this

requirement. Although the following licensed professionals are also considered

" practitioners " in accordance with Section 1842((18)© of the Social Security

Act, they generally would not be considered responsible for the care of the

patient or qualified to order rehabilitation services: Certified registered

nurse anesthetist (Section 1861(bb)(2) of the Act); Certified nurse-midwife

(Section 1861(gg)(2) of the Act); Clinical social worker (Section 1861(hh)(1) of

the Act); Clinical psychologist (for purposes of Section 1861(ii) of the Act and

as defined at 42 CFR 410.71); or registered dietician or nutrition professional.

>

> L. , PT, DPT, MBA

> Director, Physical Rehabilitation Services

> East Orange General Hospital

> phone

> fax

> pager

> " An ounce of prevention is worth a pound of cure. "

>

>

>

> __________________________________________________________

> IMPORTANT: This message contains confidential information and is intended only

for the individual(s) named.

> If you are not the named addressee, you are not authorized (either explicitly

or implicitly) to disseminate,

> distribute or copy this e-mail in any manner whatsoever. Please notify the

sender immediately by e-mail if you

> received this e-mail in error and delete this e-mail from your system.

Unintended transmission shall not

> constitute waiver of the attorney-client or any other applicable privilege.

E-mail transmission cannot be

> guaranteed to be secure or error-free as information could be intercepted,

corrupted, lost, destroyed, arrive

> late or incomplete, or contain viruses. The sender therefore does not accept

liability for any errors or omissions

> in the contents of this message, which arise as a result of e-mail

transmission.

>

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

[Guest guest]

I have owned a Private Practice and now I manage the Rehab Dept. of a large

hospital. Our hospital system does not require our employed physicians to refer

to the hospital's outpatient clinics. However, we do cultivate a culture around

easing the way of our patient's through our multiple layers of care. We compete

with private practices and physician owned practices just as you do. I am sure

that not all hospitals operate like we do. That said, it seems that many who

post on this list serve seem to be dividing our profession by labeling hospital

outpatient systems as the enemy. That is painful given that many hospital Rehab

Directors are quite active in the APTA, operate excellent practices that meet

Joint Commission requirements ( which are very stringent and cost a lot

resources to meet) and have to figure out ways to serve the uninsured. When I

was in private practice, I had access to many contracts that the hospital

systems in town could not get. In fact, the best contracts in town are not

available to my hospital system but are available to private practitioners.

This is just business. No one gets everything. Here in Oregon, our system is

going to be part of an ACO. I envision that we will need some help in treating

the extra 600,000 Oregonians that are going to become insured. Will the

reimbursement be good? I don't think so. Will we need to come up with a new

model to deliver care? I think so. Will that involve practices that are not a

part of our system? I think so. However, we will choose carefully. Our

average number of visits per patient is between 6 - 7. Our outcomes are great

and our patients are satisfied. So, we will want to partner with practices that

can match our outcomes and our average number of visits. I am hopeful that

there will be many colleagues who will want to work with us.

From: PTManager [mailto:PTManager ] On Behalf Of

selenahorner

Sent: Saturday, January 14, 2012 2:41 PM

To: PTManager

Subject: Re: outpatient referrals by nonstaff MDs

Historically, hospital systems like to keep the gravy train going within their

own system. From acute care to rehab to home health to outpatient services, the

unwritten rule is to keep the patient within the hospital system, not for

continuity of care as much as increased profits.

Hospital systems are jumping on the ACO bandwagon and are buying out physician

practices within surrounding communities.

Generally speaking, hospital systems do have outpatient physical therapy

satellites in communities. This means there isn't inconvenience to patients in

various communities surrounding the large hospital headquarters.

Reality... hospital systems have physicians who use hospital referral pads when

making referrals. People who have this piece of paper in their hot little hands

contact or choose from services on that sheet of paper. The choices on that

sheet of paper only direct the hospital patients to hospital locations for

services. It is completely unheard of for a hospital system to provide options

outside of the system. It is also unheard of for that piece of paper to

communicate freedom of choice for services.

Hospital systems have monopolized this way for years without divulging facts &

the freedom of choice to patients within their system. Hospital systems have a

very large chunk of a population in any area who utilize services. Hospital

systems monitor referral patterns. Private practices and freedom of choice have

been ignored for years on this particular topic.

I'm not for more and more regulations. I think it creates increased cost to

verify medical staff privileges. Does this truly limit freedom of choice? Not

completely. Remember, patients have the freedom to choose and that freedom isn't

captured by any hospital system anyways because full disclosure doesn't occur in

the real world. It forces hospital systems to grant every physician within their

system medical staff privileges. Remember, the unwritten rule is to refer within

the system.

The only logical way to determine departmental impact of this - because really,

you are all talking money and the loss of revenue - is to dig into your

databases and analyze your top 25 referral sources. How many of those referral

sources are not already within the hospital system? And... from that, how many

of those currently within the hospital system do not have medical staff

privileges?

To understand the full " effect " of this, what's the data indicate?

And, for those of you in private practice. Now would be a nice time to question

your top referral sources and learn who has privileges where. You can educate

them on their options for where to refer for physical therapy services based on

this new regulation. If you happen to have referral sources without privileges

and you just happen to compete with a hospital system - especially a hospital

system that isn't a team player in the community, you could share a referral

source NPI number and contact your Medicare payer questioning if they have paid

for services at the hospital site.

Selena Horner, PT

ton, MI

>

> Good afternoon for those practicing in hospitals that see outpatients how is

the new CMS interpretations affecting you if the doctor is not on staff of the

hospital they can no longer refer to the hospital. I copied the language and the

link below it was effective November 18, 2011.

>

> http://www.cms.gov/transmittals/downloads/R72SOM.pdf

>

> §482.56( Standard: Delivery of Services

> Services must only be provided under the orders of a qualified and licensed

practitioner who is responsible for the care of the patient, acting within his

or her scope of practice under State law, and who is authorized by the

hospital's medical staff to order the services in accordance with hospital

policies and procedures and State laws.

> Interpretive Guidelines §482.56(

> Rehabilitation services must be ordered by a qualified and licensed

practitioner who is responsible for the care of the patient. The practitioner

must have medical staff privileges to write orders for these services.

Privileges must be granted in a manner consistent with the State's scope of

practice law, as well as with hospital policies and procedures governing

rehabilitation services developed by the medical staff and approved by the

governing body. Practitioners who may be granted privileges to order

rehabilitation services include physicians, and may also, in accordance with

hospital policy, be extended to Nurse Practitioners, Physicians' Assistants, and

Clinical Nurse Specialists as long as they meet the parameters of this

requirement. Although the following licensed professionals are also considered

" practitioners " in accordance with Section 1842((18)© of the Social Security

Act, they generally would not be considered responsible for the care of the

patient or qualified to order rehabilitation services: Certified registered

nurse anesthetist (Section 1861(bb)(2) of the Act); Certified nurse-midwife

(Section 1861(gg)(2) of the Act); Clinical social worker (Section 1861(hh)(1) of

the Act); Clinical psychologist (for purposes of Section 1861(ii) of the Act and

as defined at 42 CFR 410.71); or registered dietician or nutrition professional.

>

> L. , PT, DPT, MBA

> Director, Physical Rehabilitation Services

> East Orange General Hospital

> phone

> fax

> pager

> " An ounce of prevention is worth a pound of cure. "

>

>

>

> __________________________________________________________

> IMPORTANT: This message contains confidential information and is intended only

for the individual(s) named.

> If you are not the named addressee, you are not authorized (either explicitly

or implicitly) to disseminate,

> distribute or copy this e-mail in any manner whatsoever. Please notify the

sender immediately by e-mail if you

> received this e-mail in error and delete this e-mail from your system.

Unintended transmission shall not

> constitute waiver of the attorney-client or any other applicable privilege.

E-mail transmission cannot be

> guaranteed to be secure or error-free as information could be intercepted,

corrupted, lost, destroyed, arrive

> late or incomplete, or contain viruses. The sender therefore does not accept

liability for any errors or omissions

> in the contents of this message, which arise as a result of e-mail

transmission.

>

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.