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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

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

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

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

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

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