(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 10029 Northshore Medical Group Medical Records Huntington, NY K M

INSURANCE SIGNATURE I request that payment of authorized Medical Benefits be made either to me or on my behalf to the Department of Orthopaedics — Faculty Practice Associates for any service furnished to me by my physician. I authorize any holder of medical information about me to be released to the Health Care Financing

Queens Medical Records 25-10 30' Avenue Long Island City. NY 11102 For Mount Sinai Use Only Date Received: (MO/DY/YR) Disposition of Request. Faculty Practice Associates Patient Rights Coordinator One Gustave L Levy Place - Box 1621 New York. NY 10029 Northshore Medical Group Medical Records Huntington. NY GRAN