Epstein Secrets

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

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

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

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

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

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