01/15/2013 00:10
01/15/2013 00:10
I tie DIU UM aata1 MOLird: Mount Hospital Sinai • Sinai of C&eens
A nMakao allx1/-aunt Slit ReeptTal
PATIENT A LESS REOV/E,ST FOR pito:0AL INFORMATION I----- Attu: Georgette Smith
IlligielPPi allieco Records
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
•
O Entire Designated Record Set
13 Inpatient Visit(s)
CI ED Visit(s)
❑ Ambulatory Surgery
O Outpatient Clinic— Manhattan
b AHC
Dialysis
0 IMA
a Jack Martin
NRC
OBIGYN
O Pediatrics
0 Psychiatry
0 Radiation Oncology
0 Specialty
O Outpatient Clinic QUeens
e Family Health Associates
= Senior Health Center
0 Industrial Health Center
ID FPA Practice/Provider. Bill Date(s) of Service Document(s)
❑
El
❑
o
❑
❑ ❑❑
O
0 X-ray Filins/Repons
El Pathology Slides/Reports
❑ Other ❑
O
El
❑
. o
MR-200 (3/03) 1- Medical Records Copy COOO1:1O1:3OOO1:3O CTA/CT SCAN
MRI - MRA
ULTRA -SOUND
PET SCAN
X-RAY
BONE DENSITY
MAMMO
CD
REPORT
PICK UP
MAIL TO HOME
MAIL TO OTHER
4 ,
2- Patient Copy
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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
Medical Records
One Gustave L. Levy Place — Box 1111
New York, N.Y. 10028
O Mount Sinai Hospital Queens
Medical Records
25-10 3e Avenue
Long Island City, NY 11102
O Other: O FPA Patient Rights Coordinator
One Gustave L. Levy Place — Box 1061
New York, NY 10028
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): 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