01/15/2013 00:10

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 ig Sn re . Personal Representative PRINT NAME: 1.--GS)1.---5-. \I (2? f:- goP: Authority; -pag_s,O1.1AL- A9 SIST";473.1-- Date: Address' 9 to ST q-n i ST" s\ I \ia NI\VOCt)-1 Tel No. Need By. NIP V 15raCt3 Reason. -DOC:TOR APPOI 1dt 11/4-4 GAT* Send completed form to the most appropriate area listed below. Date: \/, /El acia O Mount Sinai Hospital Medical Records One Gustave L. Levy Place — Box 1111 New York, N.Y. 10028 O Mount Sinai Hospital Queens Medical Records 25-10 30th Avenue Long Island City, NY 11102 O Other: O FPA Patient Rights Coordinator One Gustave L. Levy Place - Box 1061 New York, NY 10028 O Northshore Medical Group Medical Records Huntington, NY 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