EFTA00313617.pdf

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 I-IIV-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 retease 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 Cate 12/14/2016 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. Faculty Practice Associates Patient Rights Coordinator One Gustave L Levy Place - Box 1621 New York. NY 10029 Northshore Medical Group Medical Records Huntington. NY GRANTED DENIED PARTIALLY DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) Fee Charged For Fulfilling This Request (if applicable) S Name or initiais/ offtecords blepartment Staff Member Processing This Request - Ed Mail Out L K Will Pick -Th` _2--Vatient Cop' 1 — Medical Records Copy MR-201 (REV 3/15) EFTA00313617