Fillable AMERICANS WITH DISABILITIES ACT (ADA) ATTESTATION (EmblemHealth)

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AMERICANS WITH DISABILITIES ACT (ADA) ATTESTATION (EmblemHealth)

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FROM: Practice Name:
Address:
City: State: ZIP:
Instructions: Please answer each question and subquestion by lling in the appropriate circle. en, based on your practice
location, mail the completed attestation and any related documentation to:
New York City, Nassau, Suolk:
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 oce. 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. Does the office have at least one wheelchair-accessible path from an entrance to an exam room?
Yes No N/A
2. Are examination tables and all equipment accessible to people with disabilities?
Yes No N/A
3. If parking is provided, are there spaces reserved for people with disabilities and pedestrian ramps at
sidewalks and drop-offs?
Yes No N/A
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
Yes No N/A
5. a. For 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?
Yes No N/A
b. Is the path of travel stable, firm and slip resistant?
Yes No N/A
c. Except for curb cuts, is the path at least 36 inches wide?
Yes No N/A
6. a. Is there a method for persons using wheelchairs or requiring other mobility assistance to enter as
freely as everyone else?
Yes No N/A
b. Is that route of travel safe and accessible for everyone, including people with disabilities?
Yes No N/A
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.
Yes No N/A
b. 18 inches of clear wall space on the pull side of the door, next to the handle.
Yes No N/A
c. The threshold edge is no greater than ¼-inch high; if beveled, no greater than ¾-inches high.
Yes No N/A
d. The door handle is no higher than 48-inches high and can be operated with a closed fist.
Yes No N/A
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
(Continued)
AMERICANS WITH DISABILITIES ACT
(ADA) ATTESTATION
8. a. Are there ramps to permit access? If yes, complete the following four questions:
Yes No N/A
b. Are the slopes of the ramp accessible for wheelchair access?
Yes No N/A
c. Are the railings sturdy and high enough for wheelchair access?
Yes No N/A
d. Is the width between railings wide enough to accommodate a wheelchair?
Yes No N/A
e. Are the ramps nonslip and free from any obstruction (cracks)?
Yes No N/A
9. If there are stairs at the main entrance, is there also a ramp or lift or is there an alternative
accessible entrance?
Yes No N/A
10. Do any inaccessible entrances have signs indicating the location of the nearest accessible entrance?
No N/A
11. Can the accessible entrance be used independently and without assistance?
Yes No N/A
12. Are doormats ½-inch high or less with beveled or secured edges?
Yes No N/A
13. Are waiting rooms and exam rooms accessible to people with disabilities?
Yes No N/A
14. Does the layout of the interior of the building allow people with disabilities to obtain materials and services
without assistance?
Yes No N/A
15. Do the interior doors comply with the criteria set forth for exterior doors (see question 7)?
Yes No N/A
16. Are the accessible routes to all public spaces in the facility 31-inches wide?
Yes No N/A
17. Is there a 5-foot circle or a T-shaped space for a disabled person using a wheelchair to reverse
direction in public areas where services are rendered?
Yes No N/A
18. Are all buttons or other controls in the hallway no higher than 42 inches?
Yes No N/A
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 No N/A
b. The controls inside the cab have raised and Braille lettering.
Yes No N/A
c. The call buttons in the hallway are not higher than 42 inches.
Yes No N/A
20. Are sign language interpreters and other auxiliary aids and services provided in appropriate circumstances?
Yes No N/A
21. Is the public lavatory wheelchair-accessible?
Yes No N/A
22. With respect to the public restroom, do the accessible route, the exterior door and the interior stall doors
comply with standards set forth for exterior doors (see question 7)?
Yes No N/A
23. Is there at least one wheelchair-accessible stall in the public restroom that has an area of at least
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)?
Yes No N/A
24. In the accessible stall of the public restroom, are there grab bars behind and on the side wall nearest
the toilet?
Yes No N/A
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 No N/A
b. A maximum of 19 inches of the required depth may be under the lavatory.
Yes No N/A
c. The lavatory rim is no higher than 34 inches.
Yes No N/A
d. There are at least 29 inches from the floor to the bottom of the lavatory apron.
Yes No N/A
e. The faucet can be operated with a closed fist.
Yes No N/A
f. The soap dispenser and hand dryers are within reach and usable with one closed fist.
Yes No N/A
g. The mirror is mounted with the bottom edge of the reflecting surface 40 inches from the
floor or lower.
Yes 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:
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AMERICANS WITH DISABILITIES ACT (ADA) ATTESTATION (EmblemHealth)

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Completed 5 May 2022

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