EFTA00283624.pdf

01/15/2013 00:10 I tie DIUUM aata1 MOLird: Mount Hospital I ----- Sinai • Sinai ofC&eens Attu: Georgette Smith A nMakao allx1/-aunt Slit ReeptTal Illi g e i lPPiRec ecoordall s i PATIENT A LESS REOV/E,ST FOR pito:0AL INFORMATION Fax No. Patient's Name: • (Last) (First) (Middle) Date of Unit Number: Birth: let. No. / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED. o on-efts inspection O record copy @ S.75/page Records • Bill Date(s) of Service Document(s) O Entire Designated Record Set 13 Inpatient Visit(s) ❑ CI ED Visit(s) El ❑ Ambulatory Surgery O Outpatient Clinic— Manhattan b AHC ❑ Dialysis o COOO1:1O1:3OOO1:3O 0 IMA ❑❑ CTA/CT SCAN a Jack Martin MRI - MRA NRC ❑ OBIGYN ❑ ULTRA-SOUND O Pediatrics PET SCAN 0 Psychiatry 0 Radiation Oncology O X-RAY 0 Specialty BONE DENSITY O Outpatient Clinic QUeens e Family Health Associates ❑ MAMMO = Senior Health Center O CD 0 Industrial Health Center ID FPA Practice/Provider. REPORT PICK UP MAIL TO HOME 0 X-ray Filins/Repons El Pathology Slides/Reports El MAIL TO OTHER ❑ ❑ Other . o 4, MR-200 (3/03) 1- Medical Records Copy 2- Patient Copy EFTA00283624  01/15/2013 00:10 2122419987 PAGE 02/02 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 ff I do not want to pay those fees. * Patient 3if Date: Signature Personal Representative • PRINT NAME: Signature Authority: Date: . Address: Tel No. Need By: Reason: Send completed form to the most appropriate area listed below. ❑ 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 Northshore Medical Group Medical Records Medical Records • 25-10 3e 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): 5 Name or Initials of Records Department Staff Member Processing This Request CI Mail Out O Will Pick Up 1- Medical Records Copy 2 - Patient Cdpy EFTA00283625