EFTA00313617.pdf

and may be revoked by me I understand that this authorization is valid for one year from this date or until on my authorization. at any time except to the extent Mount Sinai has already taken action based SPECIFIC UNDERSTANDINGS Psychiatric records and or HIV- I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or an -related test. or have HIV infection. HIV -related illness or AIDS, or that related information (indicating that I have had I-IIV could indicate that I have been potentially exposed to HIV). from redisclosing any HIV-related If I am authorizing the release of HIV-related information, the recipient(s) is prohibited information without my authorization unless permitted to do so under federal and state law. I also have a right to request a list of information without authorization . If you experience discrimination because of people who may receive or use my HIV-related of Human Rights at (800) the retease or disclosure of HIV-related information, you may contact the New York State Division 523-2437/(212) 480-2493 or the New York City Commission on Human Rights at (212) 306-7450. information as described above. By signing this authorization form, I am authorizing the use or disclosure of my protected health redisclosed if the recipient(s)as described on this form is not required by law to protect the privacy of This information may be information privacy regulations. the information, and such information is no longer protected by federal health 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 Faculty Practice Associates Medical Records Patient Rights Coordinator One Gustave L. Levy Place - Box 1111 One Gustave L Levy Place - Box 1621 New York, NY 10029 New York. NY 10029 Mount Sinai Hospital Queens Northshore Medical Group Medical Records Medical Records 25-10 30' Avenue Huntington. NY 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) S / offtecords blepartment Staff Member Processing This Request - Name or initiais Ed Mail Out L ❑ Will Pick -Th` 1 — Medical Records Copy _2--Vatient Cop' MR-201 (REV 3/15) EFTA00313617