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Tip Sheets for Caregivers of Individuals with Special Health Care Needs Understanding Emotional Responses to Disability Coping with Your Child’s Health Care Needs Reducing Stress Organizing and Keeping Records Making the Most of Medical Appointments Managing Prescriptions Researching Health Care Information on the Internet When Your Child Has Been Diagnosed with a Disability or Chronic Condition About Parent to Parent of NY State / Contact Information Compiled by the Parent to Parent of NYS Family to Family Health Information Center A publication of ---PAGE BREAK--- © 2013 Parent to Parent of NYS ---PAGE BREAK--- © 2013 Parent to Parent of NYS Tip Sheets for Caregivers of Individuals With Special Health Care Needs Included in this booklet are Tip Sheets compiled by parents and caregivers of children with special needs as a way of sharing practical advice and knowledge gained through their experience with other parents and caregivers of children facing exceptional health care challenges. The following pages, as well as other Fact Sheets and Tip Sheets, may be downloaded at no cost at the following web page: Family-to-Family Health Information Centers (F2F HICs): Family-to-Family Health Information Centers (F2F HICs) are nonprofit organizations that help families of children and youth with special health care needs and the professionals who serve them. Because the health care needs of are chronic and complex, parents and caregivers are often challenged with finding the resources to provide and finance health care for their children. F2F HICs are in a unique position to help families because they are typically staffed/run by parents of themselves, and as parents, they have traveled through the maze of services and programs designed to help Staff members at F2F HICs understand the issues that families face, provide advice, offer a multitude of resources and tap into a network of other families and professionals for support and information. How do F2F HICs help? The Health Resources and Services Administration’s (HRSA) Maternal Child Health Bureau (MCHB) provides the primary funding support for F2F HICs, as authorized by the Family Opportunity Act (FOA), legislation signed into law in 2006 (as a part of the Deficit Reduction Act). Through this funding, HRSA's MCHB currently supports F2F HICs. Do you have a child with special health care needs? Would you like to speak to staff at New York’s Family to Family Health Information Center? Contact the statewide Project Director at [PHONE REDACTED] or [PHONE REDACTED]. Do you have a practical tip that you would like to share with other families? Join the Medically Fragile E-group and share your experience. The purpose of the group is to disseminate and share information regarding children who have complex medical needs. For more information, visit: Sign up to receive the Links Digest, a compilation of website links to assist families in their ongoing research, Current and previous editions are available at: ---PAGE BREAK--- ---PAGE BREAK--- © 2013 Parent to Parent of NYS Tip Sheets for Caregivers of Individuals with Special Health Care Needs Table of Contents Page(s) 1. Understanding Emotional Responses to Disability 4-5 2. Coping with Your Child’s Health Care Needs 6 3. Reducing Stress 7 4. Organizing and Keeping Records 8 5. Making the Most of Medical Appointments 9 6. Managing Prescriptions 10-11 7. Researching Health Care Information on the Internet 12-13 8. When Your Child Has Been Diagnosed with a Disability or Chronic Condition 14-16 9. About Parent to Parent of New York State 17 10. Parent to Parent of NYS Contact Information 18 ---PAGE BREAK--- ---PAGE BREAK--- © Parent to Parent of NYS 4 UNDERSTANDING EMOTIONAL RESPONSES TO DISABILITY Emotions have to be recognized and validated in order to best advocate for and support our children with exceptional challenges. Common Reactions: Shock – It doesn’t make sense; it wasn’t supposed to happen to me. I took care of myself. Fear – What will happen to my child? What about our dreams for our child and our dreams for ourselves? What about my job? Will I be able to work? Denial – Acceptance of this situation and lifestyle come ever so gradually. Denial is a period of searching for answers, searching for treatments, searching for cures. Denial prevents the bad news from hitting all at once. Anxiety – What do I do to reduce my feelings of powerlessness? What do I do to help my child? Anxiety mobilizes the energy required to face these new challenges. Financial Impact: • One parent often becomes unemployed or underemployed. • Household finances are impacted when medical necessitate difficult decisions that affect other expenses – clothes, groceries, medical bills. Forget vacations. Stigma of disability – history Medical model – a person with a disability is sick or “disabled” and therefore excused from typical societal obligations like going to school, getting a job, taking on family responsibilities, etc. Rehabilitation model – having a disability is a deficiency that must be fixed by rehabilitation professionals or other helping professionals. What is your frame of reference about disability? Preconceived notions – The messages we hear from the larger world: • Focus on the glass half empty – the disability, the “can’t do”, the burden. • The words we hear: suffer, burden, courageous, victim, special, crippled, stricken. • Negative and false stereotypes: People with disabilities don’t work; people with disabilities are criminalized, victimized, exploited, perverts, failures, or can’t learn. • Disability is viewed with fear, discomfort and loss. It is stigmatized; the emphasis is on correcting and curing disability. ---PAGE BREAK--- © Parent to Parent of NYS 5 • Stereotypes about people with disabilities often are a result of an emphasis in American culture on what and how much a person can produce, or how athletic or academically gifted people are. • People with disabilities are laughed at and teased. The challenge for families: • We love our child, but because of perceptions and attitudinal barriers in everyday life, we feel isolated. • We struggle with grasping that we are now part of the world of disability that has been perceived so negatively. • We know our child can learn if given the right supports, but not everyone shares the same belief. How does a family reconcile? • Be honest with your feelings. • Take one day at a time. • Never underestimate your child’s potential. • Encourage your child to develop to the best of their ability. • Find positive mentors, other parents and professionals who recognize your child’s special gifts. • Recognize your role as expert on your child and be involved with their educational program and medical care. • Focus your attention on the positive contributions your child with special needs has made on the family. • Believe your child will learn. • Let a child be a child first. Therapies and interventions may be necessary but remember: You have a child who wants to play. Support Parents With the assistance of families throughout New York State, Parent to Parent has developed a network of parents throughout the state who serve as Support Parents. Support Parents have offered to speak to other families and caregivers who are facing similar challenges. Would you like to join our network of parents helping parents and become a Support Parent willing to speak with other parents? If you have questions or need information about your child’s disability or health care needs, contact Parent to Parent at any one of our offices listed on Page 18. ---PAGE BREAK--- © Parent to Parent of NYS 6 COPING WITH YOUR CHILD’S SPECIAL HEALTH CARE NEEDS Understand your feelings. Express your emotions. Educate yourself about your child’s illness or condition. Keep communications open. Talk to other parents. Focus on the and goals that are achievable. Believe in your child. Establish routines. Maintain your sense of humor! There is no co-pay for laughter!! Remember that taking care of yourself is caring for your family. Helpful websites: www.ptopnys.org www.parenting-ed.org/for-parents www.medicalhomeinfo.org www.caringtoday.com/ www.caregiver.com http://lend.umn.edu/docs/LEND-Family_Caregiver-FACT_SHEET-7-3-13.pdf Contact your regional Parent to Parent office to network with other parents (see page 18). ---PAGE BREAK--- © Parent to Parent of NYS 7 REDUCING STRESS: STRESS REDUCTION TIPS FOR PARENTS OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS OR CHRONIC ILLNESS Bury your guilt in the backyard. Be a mother or a father, not a therapist. Reach out – parents helping other parents are powerful and healing. Consider how your child’s illness or disability impacts the family in a positive way. Examples: Your family has become more accepting of differences. You have met some great people who otherwise would not have been part of your life. You have learned the importance of clear communication and advocacy. Live in the present and enjoy the good times. Keep a picture of the good times with you. Take deep breaths regularly. Take more deep breaths. Laughter is therapeutic. Guilt is a self-made emotion. Make guilt-free time for you. Do something you enjoy doing, even if it doesn’t include your family. Recognize your family’s and build upon them. ---PAGE BREAK--- © Parent to Parent of NYS 8 ORGANIZING & KEEPING RECORDS An important part of raising a child is keeping records of the major events in your child’s life. As a parent of a child with special health care needs or a disability, this record keeping goes beyond when your daughter got her first tooth or when your son broke his arm. Why keep records? It is important to have medical information in one easily accessible place. Keeping track of your family’s medical information can prevent unnecessary stress. If you move or change doctors, you will be able to share your medical history with the new doctor before your “official” records get forwarded. What records should I keep? Keep all relevant information related to your child, including: 1. Dates of immunizations, hospitalizations, illness, surgeries 2. Contact information and dates of service for: doctors, specialists, dentists, surgeons, therapists, insurance companies, schools 3. Phone conversation logs for: medical professionals, insurance providers 4. Medications 5. Insurance information (copy of policy and correspondence) 6. Education/school documents (i.e. 504 Plan, notes from nurse, etc.) 7. Equipment, supplies and vendor information 8. Emergency contact information 9. Other information specific to your child Where do I start to organize records? 1. Start with today, this month, this year. 2. Don’t let the overwhelming thought of organizing prevent you from beginning. 3. Find a method that works for you and use it. 4. The best method is one that you will use regularly. Some suggestions: 1. File folders, accordion folders, notebooks and a specific box or file drawer all work as locations to keep records. Find what works best for your lifestyle. 2. Use a different folder, notebook, box or file drawer for each child. 3. Go through your records annually to keep them current and up to date. ---PAGE BREAK--- © Parent to Parent of NYS 9 MAKING THE MOST OF MEDICAL APPOINTMENTS 1. Find out the regular and walk-in hours for each doctor’s office, hospital and/or clinic. Try to schedule your appointment first thing in the morning or immediately after lunch. 2. If possible, schedule a few appointments in one day to save money on gas, parking and childcare for siblings; you will be reducing the time and distance you travel, making it less stressful on you and your child. 3. Call before your appointment to see if the doctor is in and running on time. 4. Leave ample time for parking. 5. Bring extra money for parking, co-pays and lunch. 6. Develop a system to organize contact information (names, email addresses, phone and fax numbers, etc.) that you will need at various appointments, including pertinent doctors, labs, pharmacists, SSI numbers, ID numbers, etc. 7. Use one calendar for everything – it will help you avoid missing appointments. If you are writing appointments on different calendars, you may overlook an appointment. If possible, record the contact information for each doctor on the calendar in case an appointment must be canceled or rescheduled. 8. Keep a bag packed for your doctor visits at all times. In an emergency, you will have contact information, toys, phone numbers, snacks, drinks and medications ready, and you can avoid wasting time looking for these important items. ---PAGE BREAK--- © Parent to Parent of NYS 10 MANAGING PRESCRIPTIONS Practical tips and questions to ask when a medication is being prescribed: 1. Clarify the dose, the number of times taken daily and the name of the medication in case there is confusion on the part of the pharmacist or doctor. 2. If a doctor is prescribing a 3-4 times per day medication, ask if there is another prescription that is equally effective but given only once or twice a day, thus reducing the chance of missing a dose. 3. Indicate what type of medication is best for your child (i.e. if they cannot swallow pills, request a liquid medication). 4. The pharmacist will give you a printout of side effects. Ask the doctor if there are any common or frequent side effects for each medication. 5. Ask the pharmacist if there are special instructions for taking a prescription (i.e. stay out of the sun; don’t take medication with dairy products or avoid dairy for one hour; take at bedtime if a medication causes drowsiness; take before eating; etc.) 6. Ask if anything should be taken along with the medication (i.e. with prednisone you should take calcium). 7. Don’t be afraid to ask the doctor for samples, especially if it’s a medication that will be taken short-term or as part of a trial. 8. Learn the brand, generic names and doses of medications your child is taking. This can help avoid prescription mistakes. 9. Do not change the form of any medication without speaking to your pharmacist (i.e. some medications can be crushed, chopped and mixed with juice). Always ask before altering a medication’s form. Sustained release pills should not be crushed and some capsules should not be opened. Check with your pharmacist. ---PAGE BREAK--- © Parent to Parent of NYS 11 10. If a medication tastes awful or if your child has many medications, see about purchasing empty capsules and putting the medications into it so that your child won’t have to taste them or swallow as many. 11. Instead of leaving numerous prescription bottles on the counter of your kitchen, designate a shelf in a cabinet. If there are a lot of prescription bottles, consider purchasing a three-level spice rack. 12. Color code bottles for each family member to make them easy to find. 13. On your calendar write down the date to order/refill a prescription along with the prescription number so that you don’t forget to renew it. This is critical with the 90 day mail away prescriptions since you have to wait to receive it. Some pharmacies have a renewal reminder system. 14. If a refill prescription looks different than a previous supply, confirm with the pharmacist that the medication is correct. Generic meds can look different. 15. If you are having difficulty with a pharmacy, request to have your insurance carrier intervene (if they are overseeing your prescription coverage). 16. Caution: Be aware that if a medication in liquid form is spilled or spit out by a child, it will alter the number of remaining doses available. Ask your doctor how to handle the situation. ---PAGE BREAK--- © Parent to Parent of NYS 12 RESEARCHING HEALTH CARE INFORMATION ON THE INTERNET Research Tips Whereas health care information was once hard to come by, today we can be buried by the volume of information turned up by a single Internet search. Since anybody can put anything on the Internet, it is very important to sift through the search engine results carefully. Here are some tips to help parents identify quality information to assist them in making good health care decisions. Types of information 1. Determine if you are looking for factual information, opinions, or both. 2. Factual information should be able to be verified from a primary information source, one which should be provided by the author. 3. If the information is an opinion, it should be clearly stated as such and the author should identify what qualifies him/her to offer this opinion. Source of Information 1. Determine who owns or sponsors the website and why they are providing the information. a. First, check the website’s domain name. i. Web addresses that end with .gov are government-owned websites; those that end with .edu are owned by educational institutions; those that end with .org are generally owned by nonprofit organizations. ii. .com websites are commercially driven or for-profit ventures. By eliminating the .com sites when beginning a search, the search can be significantly narrowed down to sites that are most likely to have evidence-based information. b. Check the website’s homepage. i. If it is not immediately apparent who is behind the website’s existence, try scrolling down to see if there is contact information at the bottom of the page. c. Check sections of the website such as “Contact Us” and “About Us”. 2. Do not assume the website owner or sponsor is the author of the information on the website. Look for a byline or for author’s information in the footer of the article or web page. You should be ---PAGE BREAK--- © Parent to Parent of NYS 13 able to easily determine what makes the author qualified to provide the information. 3. Uncover the author’s purpose in providing the information. Consider the difference in perspectives of an employee paid to write the information and, for example, a customer who writes an essay about their experiences with the company’s product. 4. Check to see if the author’s contact information is provided. Dated Information 1. Verify that each page of the website indicates when the page was last updated. 2. Make sure the article includes the date it was published or last updated. 3. Evaluate if the information is current enough for the topic you are researching. For Further Information: 1. Credibility Assessments of Online Health Information: http://jcmc.indiana.edu/vol6/issue4/eastin.html 2. A User's Guide to Finding and Evaluating Health Information on the Web: http://www.mlanet.org/resources/userguide.html 3. Finding and Evaluating Health Information on the Internet: http://www.rochesterhealth.com/healthnotes/articles/finding- and-evaluating-health-information-on-the-internet 4. Finding Reliable Health Information Online: http://www.hopkinsbayview.org/communitylibrary/reliablehealth info.html 5. MedlinePlus Guide to Healthy Web Surfing: 6. Evaluating Websites: http://www.lib.unc.edu/instruct/evaluate/?section=websites ---PAGE BREAK--- © Parent to Parent of NYS 14 When your child has been diagnosed with a disability or chronic condition… INFORMATION & TIP SHEET (Reprinted with permission) Prepared by Dr. Elizabeth Bruce on behalf of the Emotional Health Centre Unit 8, 1253 Nepean Highway, Cheltenham. 3192. Victoria. Australia. Telephone: 61 3 9584 5150 / Fax: 61 3 9584 8690 http://www.emotionalhealthcentre.com.au/ Overview The diagnosis of a chronic condition or disability in a child represents a serious personal trauma for parents. Typically, parents feel isolated and question “why me, why my child?” Naturally, mothers and fathers experience a deep sense of painful grief that is often expressed very differently and at different points of time. Sometimes the loss or its extent is not as apparent to one parent. Perhaps one parent has not been exposed to as much information specific to the child, or they have been shielded from comparisons with other children the same age. This difference in response can easily lead to misunderstandings and disconnection between partners and it is common for relationships to be under great strain. Often partners feel they cannot successfully support each other. The severe stress caused by trauma and grief can create physical appetite change, nausea, abdominal pain, changed bowel habits, alteration to normal period pattern, headaches, dizziness, palpitations and chest pains. There may be efforts to reduce distress and find emotional relief by seeking distractions. Research indicates that many parents will experience post-traumatic Such include flashbacks to the words or situation surrounding diagnosis, preoccupation and fear with how the future might unfold, a feeling of not being entirely present, for instance, feeling remote from one’s child or other children, friends and places. Sometimes parents feel that their bodies are on alert; things they did not worry about before now create fear. Naturally, there are difficulties concentrating. Post-traumatic are often more evident in mothers because they are more likely to be at home isolated with their thoughts and being responsible for managing during the day. The workplace may allow fathers, but not all fathers, to avoid the intense thinking that mothers’ experience. There are fathers who find that no amount of work distracts them from worrying. While trauma generally decrease over time, they can be resistant, particularly when traumatic information about one’s child continues. Within this climate, depression is not uncommon for parents. ---PAGE BREAK--- © Parent to Parent of NYS 15 of depression will include a range of thoughts and behaviors including a sense of “dragging” yourself around – a difficulty facing the day, disinterest in previously enjoyed activities, quick feelings of agitation or irritation, problems relaxing, a loss of personal goals, change in appetite, feelings of helplessness, becoming locked into routines wherein you feel mindless, feelings of detachment from loved ones, sometimes hostility towards them. Of course there are degrees of depression, but you will have noticed some consistent changes in you. Over time, generally parents move towards adapting to their child’s condition – a possibility that seems impossible in the beginning! It is typical for parents to often feel that they have gone backwards. However, it is a steep learning curve. It is normal for a sense of grief in varying intensity to parallel the child’s life. Looking after yourself and your family In the early period, post-diagnosis, parents need to be mindful of the trauma and the huge adaptation surrounding it. Try and guard against: too much reading, too many questions, being exposed to images that create fear of the future, or talking to individuals who are ignorant of the depth of your feelings. Pace yourself if possible. You will know when you are ready to take any next steps. Try not to run out of energy and vital nutrients by eating small meals or snacks throughout the day. Keep up fluid intake. Alternate with your partner in taking short exercise. Long periods of isolation with your own thoughts intensify negative thoughts and should be avoided if possible, if only broken up by talk-back shows at home or a brief walk. Mothers and fathers need regular support to work through aspects of this trauma. Counseling should be considered vital to emotional and physical well-being. The well-being and longevity of the relationship between mother and father is the greatest asset amidst this trauma. Relationship counseling early on is vital in respecting each partner’s unique approach to managing loss in their lives. Suffering from continuing traumatic or depression is common. In these situations the natural chemicals in the brain have become depleted through ongoing stress. Finding relief through prescribed anti-depressants or naturopathic means is crucial to well-being and healthy parenting. Medication may be short term. Some parents return to medication at different times. In tandem with counseling, parents continue to learn ways to manage. Sleep deprivation is normal. As it can easily lead to depression, relentless sleep deprivation should be tackled early. Typically respite is difficult. Parents may need to alternate sleeping arrangements, usually away from the home environment. Sometimes parents find that prescribed medication or naturopathic substances help with gaining sleep when the opportunity arises. Joining a support group of other parents in similar situations reduces perceptions of isolation. Discussion in these groups will normalize your feelings. ---PAGE BREAK--- © Parent to Parent of NYS 16 Raising a child with a chronic situation calls for specialist knowledge. Reading, seminars and consulting with professionals in parenting will avoid extra concerns and help in difficult decision-making. In the early stages of parenting, parents should avoid excessive reading as it is difficult to check what is relevant and the mind is already overwhelmed. Siblings will do well with regular special attention and paced information about their brother and sister. Back-up plans for how they can handle times of upheaval and questions from their peers will decrease anxiety. Remember that grandparents will be subjected to shock also. Try to reduce your expectations of empathic, helpful feedback, especially in the early stages. Advise family and friends of the nature and intensity of your trauma. Often they have no idea how to relate to the situation. Parents have found it useful to send information about the child’s condition to others. Checklist for getting support Are any described above persisting with the same intensity over time? Do you have consistent support from family and friends? Have you been able to express the depth of your emotions to someone? Have you been given opportunities to express your feelings about the diagnosis? Do you express your feelings often? Do you find yourself “stuck” thinking about a particular incident during diagnosis, or word(s) used during diagnosis? Are there certain experiences that you can’t get off your mind? When you look back to diagnosis or thereabouts, do you think that the depth of your feelings is getting harder to manage? Do you spend more than 8-10 hours without adult company for more than two days in a row? Does your partner generally support you? Do you feel increasing anxiety in being able to manage your child’s condition Have you been able to shake-off a feeling of “what’s the point?” Do you avoid talking about your thoughts and feelings? Resources To purchase Through Loss (Bruce, E.J. & Schultz, C.L. 2004) and other resources, visit the Emotional Health Centre’s website listed above. ---PAGE BREAK--- © Parent to Parent of NYS 17 About Parent to Parent of New York State Parent to Parent of New York State Mission: Parent to Parent of New York State builds a supportive network of families to reduce isolation and empower those who care for people with developmental disabilities or special healthcare needs to navigate and influence service systems and make informed decisions. Parent to Parent of NYS is a statewide not-for-profit organization with a mission to support and connect families of individuals with special needs. We are a point of contact for many parents who are “getting started” on their journey of parenting a child with developmental disabilities. Offices located throughout NYS are staffed by regional coordinators who themselves are parents or close relatives of individuals with special needs. A website is maintained to provide information and events listings: www.ptopnys.org. A network of Support Parents is the backbone of the Parent Matching Program. The program, created and maintained by Parent to Parent regional coordinators, is a model program used across the country to put parents in touch on a one-to-one basis with other parents who have a child with a chronic illness or disability. “Support Parents” are parents of individuals with special needs who have made the offer to speak with “new” parents and share their experiences. Support Parents are the key to this program. The organization recognizes the need for emotional support as well as the importance of parents knowing they are not alone. When parents agree to be Support Parents, they are provided a skills- building training that includes an overview of how the program works and an understanding of the emotions and life-altering changes a parent or caregiver may experience, as well as listening skills. New parents are welcome to join the Support Parent network and to share their experience. In addition to the Parent Matching program, the organization fields telephone calls from parents of children with special needs who are looking for resources, services and information. Callers include parents looking for information about medical services and therapies and those looking for information about a specific illness or disability. There are often questions about special education. All programs are based on the philosophy of parents helping each other, drawing on a network of parents helping parents. Coordinators are there to assist caregivers and parents but draw on other parents to help. There is no charge for services. The Family to Family Health Information Center (F2F HIC) assists families with access to health care, health care recordkeeping and transition from pediatric to adult health care. Information about this program can be viewed at the website. ---PAGE BREAK--- © Parent to Parent of NYS 18 Parent to Parent of NYS Contact Information: 1. WESTERN AND FINGER LAKES WESTERN NY – Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans & Wyoming 1200 East & West Road, Building 16, Room 1-173, West Seneca, NY 14224 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] FINGER LAKES – Livingston, Monroe, Ontario, Yates & Wayne c/o FL DDRO Office, 2165 Brighton-Henrietta Townline Road, Room #124 Rochester, NY 14623 Mail at: 300 Hylan Drive, PMB 153, Rochester, NY 14623 [PHONE REDACTED](fax is same as phone) SOUTHERN TIER – Chemung, Schuyler, Steuben & Seneca PO Box 205, 210-12th St. #210, Watkins Glen, NY 14891 1-[PHONE REDACTED] / [PHONE REDACTED] (fax is same as phone) 2. CENTRAL NORTH COUNTRY – Clinton, Essex, Franklin, Hamilton, Jefferson & St. Lawrence PO Box 1296, Tupper Lake, NY 12986 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] SOUTH CENTRAL NY – Broome, Chenango, Delaware, Otsego, Tioga, & Tompkins 213 Tracy Creek Road, Vestal, NY 13850 [PHONE REDACTED], x 787 / Fax: [PHONE REDACTED] (include a fax cover sheet) NORTH CENTRAL NY – Cayuga, Cortland, Herkimer, Lewis, Madison, Oneida, Onondaga & Oswego Exceptional Family Resources, 1820 Lemoyne Ave., Syracuse, NY 13208 1-[PHONE REDACTED] / [PHONE REDACTED], x 322 / Fax [PHONE REDACTED] (include a fax cover sheet) 3. CAPITAL AND HUDSON CAPITAL & TACONIC – Albany, Columbia, Dutchess, Fulton, Greene, Montgomery, Putnam, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren & Washington 500 Balltown Road, Schenectady, NY 12304 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] HUDSON VALLEY – Orange, Rockland, Sullivan & Westchester WIHD / Cedarwood Hall, Valhalla, NY 10595 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] (include a fax cover sheet) 4. NEW YORK CITY METRO NEW YORK – Manhattan, Queens, Kings & Bronx 75 Morton Street, New York, NY 10014 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] STATEN ISLAND – Richmond c/o IBR, 1050 Forest Hill Road, #108, Staten Island, NY 10314 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] 5. LONG ISLAND – Nassau & Suffolk 415-A Oser Avenue , Hauppauge, NY 11788 1-[PHONE REDACTED] / [PHONE REDACTED] / Fax: [PHONE REDACTED] BUSINESS OFFICE PO Box 1296 Tupper Lake, NY 12986 [PHONE REDACTED] Fax: [PHONE REDACTED]