PAGE 81/82 81/15/2013 00:10 ae ue eee 7 : - 1 1e IVLOULLL O11 To TT Mour M tus Hospital Attn: Georgette Smith A Division of The Mant Sinai Howptal cal Records PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Fax No, Patient's . . Nams: : ~ (Lasi) (First) (Middle) Date of Unit Number: Birth: Tel. No. / / Month/Day/Year Address: (Street) (City) (State) : (Zip Code) Please request/check all that apply: ACCESS REQUESTED O on-site inspection O record copy @ $.75!page Records Bilt Date(s) of Service Document(s} O Entire Designated Record Set go 1 Inpatient Visit(s) Oo OED Visit(s) Oo 0 Ambulatory Surgery a : . O Outpatient Clinic - Manhattan zi ~ ® ANC a oo i. ees a Q OTA/CT SCAN | o| » Jack Martin o QO mRr- MRA re is 2 CQ) ULTRA-SOUND | > Pediatrics oa Q) PET SCAN : > Psychiatry o QQ xX . RAY - @ Radiation Oncology Oo ® Specialty ‘QO BONE DENSITY O Outpatient Clinic Queens o | MAM™M O © Family Health Associates Oo = Senior Health Center 5 CQ} CD * Industrial Health Center o Q) REPORT 1D FPA Practice/Provider- Oo Ql) Pick up ee : OU) MAIL TO HOME ee Oi Xray Filns/Reports og Q) MAIL TO OTHER O Pathology Slides/Reporis a 7 0 Other . ao “S MR-200 (3/03) _ 4-Medical Revorsis Copy 2- Patient Copy EFTA00283624

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81/15/2013 08:10 2122419987 PAGE__82/62 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, | am requesting that Mount Sinai provide me with access fo health information in the manner described above, | understand that | will be contacted if any fees for a summary or explanation may be charged for futfilling this request, and that | will have an opportunity to modify or withdraw my request If | do not want to pay those fees. . : ¥ Patient : * 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: QO 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 ee New York, N.Y. 10028 . _ Q Mount Sinai Hospital Queens Q Northshore Medical Group Medical Records . Medical Records : 25-10 30" Avenue Huntington, NY Long Island City, NY 11102 Q = 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) I f Fee Charged For Fulfilling This Request (if applicable): $ Name or initials of Records Department Staff Member Processing This Request: - 0 Mail Out O Will Pick Up 4- Medical Records Copy - 2 - Patient Copy EFTA00283625