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

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

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

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