Epstein Secrets

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'S Date 12/14/2016 (Zip Code) Records to be disclosed do include do not include HIV-related information. (check One) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Att

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rts) NA R I 's Date 12/14/2016 Records to be disclosed do include do not include HIV-related information. (check one) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To 1Z Healthcare Provider O Insurance Company or Designee C At

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 Mount Sinai has already taken action based on my authorization. SPECIFIC UNDERSTANDINGS I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or Psychiatric records and or HIV- related information (indicating that I have had an I-IIV-related test. or have HIV infection. HIV-rela