61/15/2013 o:10 PAGE__082/82 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, | am requesting that Mount Sinai provide me with access to health information in the manner described above. | understand that | will be contacted if any fees for a surnmary or explanation may be charged for fulfilling this request, and that | will have an opportunity to modify or withdraw my request if | do not want to pay those fees. %K pationt HK doie: Novy. /5 2013 Personal Representative CBA Ma. PRINT NAME:_L-EQLEY GRole Authority: PERSONAL £ ANT Date: Send completed form to the most appropriate area listed below. Signature Q Mount Sinai Hospital O FPA Patient Rights Coordinator Medical Records One Gustave L. Levy Place — Box 1061 One Gustave L. Levy Place ~ Box 1171 New York, NY 10028 ‘2 New York, N.Y. 10028 : Q Mount Sinai Hospital Queens G 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 ____s:éDENIED PARTIALLY DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) I i Fee Charged For Fulfilling This Request (if applicable): $ Name or initials of Records Department Staff Member Processing This Request. 0 Mail Out 0 Will Pick Up 4- Medical Records Copy © - 2 - Patient Copy EFTA00313812