Epstein Secrets

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

ED 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: Faculty Practice Associates Patient Rights Coordinator One Gustave L. Levy Place — Box 1621 New York, NY 10

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

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

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

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