Epstein Secrets

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

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

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

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

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

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