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: GRANT

ent is a minor or incompetent). To request records or to revoke authorization 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

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

ent is a minor or incompetent}. To request records or to revoke authorization 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

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

is/her own behalf).. Need By: Reason. Send completed form to the most appropriate area listed below: a Mount Sinai Hospital Medical Records One Gustave L. Levy Place — Box 1111 New York,... 10029 0 Mount Sinai Hospital Queens Medical Records 25.10 30" Avenue Long Island City, NY 11102 G Other 0 FPA Patient

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

ddress: Tel No. Need By: Reason: Send completed form to the most appropriate 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 Patien