Epstein Secrets

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

Practice Associates Patient Rights Coordinator One Gustave L Levy Place - Box 1621 New York. NY 10029 Northshore Medical Group Medical Records Huntington. NY GRANTED DENIED PARTIALLY DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) Fee Charged For Fulfilling This Request (if

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

2 O Other: O FPA Patient Rights Coordinator One Gustave L. Levy Place - Box 1061 New York, NY 10028 O 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 R

you and yo=r family. George Raptis sings your praises and has told me a bit about all the great things you have done for breast cancer patients and Mount Sinai and the outstanding Dubin Center. I'm confident you must feel very gratified and proud with what you have achieved. I would love to catch up with yo

w I work for Northwell Health; I'm Chief of Hematology/Oncology at Huntington Hospital and Medical Director of the (outpatient) Cancer Institute at Huntington. All is well. My daughter Emily Buchholtz is a certifie= Dietitian/Nutritionist who has applied for the position of outpatient Nutritionist at the

you and your family. George Raptis sin=s your praises and has told me a bit about all the great things you have do=e for breast cancer patients and Mount Sinai and the outstanding Dubin Cent=r. I'm confident you must feel very gratified and proud with what you have a=hieved. I would love to catch up with yo

ow I work for Northwell Health; I'm Chief of Hematology/Oncol=gy at Huntington Hospital and Medical Director of the (outpatient) Cancer I=stitute at Huntington. All is well. • My daughter Emily Buchholtz is a certified Dietitian/Nutritionist=who has applied for the position of outpatient Nutritionist at t

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

hts Coordinator One Gustave L. Levy Place — Box 1061 New York, NY 10029 Northshore Medical Group Medical Records 325 Park Avenue Huntington, NY Huntington, NY 11743 For (Hospital) Use Only Date Received: (MO/DY/YR) Disposition of Request GRANTED DENIED Patient Notified in Writing Of Response On

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

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