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

privacy regulations. Patient Signature: Date: Personal Representative Signature: Print Name: Authority: Tel. No: Address: Date: (Personal Representative to sign only if patient is a minor or incompetent). To request records or to revoke authorization send a written request to: Mount Sinai Hospital

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

est, and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees if Patient Signature ig Sn re . Personal Representative PRINT NAME: 1.--GS)1.---5-. \I (2? f:- goP: Authority; -pag_s,O1.1AL- A9 SIST";473.1-- Date: Address' 9 to ST q-n i ST" s\ I \ia NI\VOCt)

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

want to pay those fees. Patient Date: Signature Personal Representative PRINT NAME: Signature Authority: Date: Address: Tel No. {Personal Representative to sign only if patient Is a minor or unable to sign on his/her own behalf).. Need By: Reason. Send completed form to the most appropriate area li