EFTA00313812.pdf

01/15/2013 00:10 PAGE 02/82 We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign we will not release your records PATIENT UNDERSTANDING AND SIGNATURE By signing below,.I am requesting that Mount Sinai provide me with access to health information in the manner described above. I understand that I will be contacted if any fees for a summary or explanation may be charged for fulfilling this request, and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees if Patient Signature Date: \/, /El acia Personal Representative . PRINT NAME: 1.--GS)1.---5-.\I (2? goP: f:- ig Sn re Authority; -pag_s,O1.1AL- A9 SIST";473.1-- Date: 9 to ST q- n i ST" s\ I \ia NI\VOCt)-1 Tel No. Address' Need By. NIP V 15raCt3 Reason. -DOC:TOR APPOI1dt 114/-4 GAT* Send completed form to the most appropriate area listed below. O Mount Sinai Hospital O FPA Patient Rights Coordinator Medical Records One Gustave L. Levy Place - Box 1061 One Gustave L. Levy Place — Box 1111 New York, NY 10028 New York, N.Y. 10028 O Mount Sinai Hospital Queens O Northshore Medical Group Medical Records Medical Records 25-10 30th Avenue Huntington, NY Long Island City, NY 11102 O Other: For (Hospital) Use Only Date Received' (MO/DY/YR) Disposition of Request GRANTED DENIED PARTIALLY DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) Fee Charged For Fulfilling This Request (if applicable): S Name or Initials of Records Department Staff Member Processing This Request: El Mail Out O Will Pick Up 1- Medical Records Copy . 2 - Patient Copy 1 EFTA00313812