Provider Profiles Submission Form

Full name *

Type your first name followed by your last name (for example, “Emma Johnson”).

Preferred pronouns

Type your preferred personal pronouns.

Credential(s)

Enter your credentials in the order you wish them to appear, separated by commas. Do not use periods. Example: "MD, MPH" not "M.D., M.P.H." Please do not rewrite your name.

Job title(s) *

If you have more than one title, put each title on a new line. Please do not exceed more than three titles.

Languages spoken (other than English):

Separate each with a comma.

Education and training:

List your bachelor's, master's or post-graduate degree programs, residency and/or fellowship(s), as applicable. Put each training experience on a separate line. Do not use punctuation and do not exceed more than 6 entries.

Professional certifications or affiliations:

List any additional certifications you hold, committee appointments, or other professional memberships or titles. Put each one on a separate line. Do not use punctuation.

Professional interests: *

List each on a separate line. Do not use punctuation.

Professional experience and accomplishments:

A little about me:

In one or two sentences, tell us something about yourself. This can be about your years of experience, special expertise or approach to clinical services. Remember, this will be seen by patients and the public.

Why do you love what you do? *

In one or two sentences, tell us why you do this work.

Staff group (check all that apply):

If you are a resident, fellow or faculty member, which program(s) are you affiliated with (check all that apply):

Addiction Medicine Fellowship

ECRIP Fellowship

Harlem Residency in Family Medicine

Icahn School of Medicine at Mount Sinai (Downtown Residency in Urban Family Medicine)

Integrative Family Medicine Fellowship

Mid-Hudson Family Medicine Residency Program

Nurse Practitioner Fellowship

Reproductive Health Care and Advocacy Fellowship

If you are a resident or fellow, what is your post graduate year?

PGY 1

PGY 2

PGY 3

PGY 4

Patient care region (check all that apply):

Patient care locations:

Please select all locations where you are available to see patients.

Which photo can we use in your profile? *

Upload your photo (your photo should be a clear shot of your face, with minimal objects in the background):

Drop a file here or click to upload Choose File

Maximum upload size: 3MB

Provider Profiles Submission Form

Use this form to create your short professional profile that will appear on MyChart, on our website and in the printed binders kept at the practices. Please do not include any information you do not want made public.