Get Mount Sinai Information 2013-2024

Date Signature Personal Representative PRINT NAME Authority Need By Reason Send completed form to the most appropriate area listed below Mount Sinai Hospital Medical Records One Gustave L. Levy Place Box 1111 New York N.Y. PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient s Name Last Unit Number First Middle DOB Tel* No* / Month/Day/Year Address Street City State Zip Code Please request/check all that apply ACCESS REQUESTED on-site inspection record copy. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. PATIENT UNDERSTANDING AND SIGNATURE By signing below I am requesting that Mount Sinai provide me with access to health information in the manner described above. I understand that I will be contacted if any fees for a summary or explanation may be charged for fulfilling this request and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees. 10029 FPA Patient Rights Coordinator th 25-10 30 Avenue Long Island City NY 11102 Northshore Medical Group 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 This Date MO/DY/YR PARTIALLY DENIED / Fee Charged For Fulfilling This Request if applicable Name or Initials of Records Department Staff Member Processing This Request Mail Out Will Pick Up 2 - Patient Copy. PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient s Name Last Unit Number First Middle DOB Tel* No* / Month/Day/Year Address Street City State Zip Code Please request/check all that apply ACCESS REQUESTED on-site inspection record copy. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. PATIENT UNDERSTANDING AND SIGNATURE By signing below I am requesting that Mount Sinai provide me with access to health information in the manner described above. .