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

ED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) Fee Charged For Fulfilling This Request (if applicable): $ Name or Initials of Records Department Staff Member Processing This Request: Faculty Practice Associates Patient Rights Coordinator One Gustave L. Levy Place — Box 1621 New York, NY 10

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

ED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) Fee Charged For Fulfilling This Request (if applicable): S Name or Initials of Records Department Staff Member Processing This Request: El Mail Out O Will Pick Up 1- Medical Records Copy . 2 - Patient Copy 1 EFTA00313812

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

Patient Notified in Writing Of Response On This Date: (MO/DY/YR) / Fee Charged For Fulfilling This Request (if applicable): $ Name or Initials of Records Department Staff Member Processing This Request: PARTIALLY DENIED 17 Mail Out 1- Medical Records Copy K Will Pick Up 2 - Patient Copy MR-200 (Rev 1/13) E

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

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