EFTA00306876.pdf

Mount Sinai PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY Patient's Name: (Last) (First) (Middle) Date of Unit Number: Birth: Tel. No.: / MontIVDay/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: I authorize Mount Sinai to disclose medical information about my: K Manhattan K Queens K Huntington _Emergency Room visit on: Date(s) _OPD Clinic visit. specify clinic: Date(s) FPA Practice/Provider Name of Provider Date(s) Hospitalization from: to Admission Date(s) Discharge Date(s) Ambulatory Surgery: Date: _Specify (i.e. Lab tests, Operative Reports) Date Records to be disclosed do include do not include HIV-related information. (check one) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Attorney K Court K Law Enforcement K Employer Other: Name: Address: Reason for Disclosure K Patient Request K Other: 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. 1 — Medical Record Copy 2- Patient Copy MR-201 (REV 3/15) EFTA00306876 I understand that this authorization is valid for one year from this date or until and may be revoked by me at any time except to the extent Mount Sinai has already taken action based on my authorization. SPECIFIC UNDERSTANDINGS I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or Psychiatric records and or HIV- related information (indicating that I have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or that could indicate that I have been potentially exposed to HIV). If I am authorizing the release of HIV-related information, the recipient(s) is prohibited from redisclosing any HIV-related information without my authorization unless permitted to do so under federal and state law. I also have a right to request a list of people who may receive or use my HIV-related information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the New York State Division of Human Rights at (800) 523-2437/(212) 480-2493 or the New York City Commission on Human Rights at (212) 306-7450. By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above. This information may be redisclosed if the recipient(s)as described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations. Patient Signature: Date: Personal Representative Signature: Print Name: Authority: Tel. No: Address: Date: (Personal Representative to sign only if patient 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 Date Received: (MO/DY/YR) Disposition of Request: GRANTED DENIED PARTIALLY DENIED 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 10029 Northshore Medical Group Medical Records Huntington, NY K Mail Out O Will Pick Up 1 - Medical Records Copy 2 - Patient Copy MR-201 (REV 3/15) EFTA00306877