Epstein Secrets

ion send a written request to: Mount Sinai Hospital Medical Records One Gustave L. Levy Place - Box 1111 New York, NY 10029 Mount Sinai Hospital Queens Medical Records 25-10 30' Avenue Long Island City. NY 11102 For Mount Sinai Use Only Date Received: (MO/DY/YR) Disposition of Request. Faculty

I understand that this authorization is valid for one year from this date or until and may be revoked by me at any time except to the extent Mount Sinai has already taken action based on my authorization. SPECIFIC UNDERSTANDINGS I understand that this consent may include disclosure of Alcohol and Dru

ow. 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 Ne

zation. 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 expla

is K O IMA = Jack Martin K K 0 NRC K 0 OB/GYN K O Pediatrics K O Psychiatry K O Radiation Oncology K O Specialty K Outpatient Clinic Queens O Family Health Associates O Senior Health Center o Industrial Health Center K K K K K FPA Practice/Provider: K K K X-ray Films/Reports K

tion. However, if you refuse to sign we will riot 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 expla

riate area listed below. K 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

tion. 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 expla