Patient Authorization For Release Of Medical Information To Third Party Form (Page 2 of 2) in 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 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/AIDS, Alcohol or Drug treatment, or mental health treatment related

information the recipient(s) is prohibited from redisclosing the 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 unable to sign on his/her own behalf}

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

Mount Sinai Hospital Queens

Northshore Medical Group

Medical Records

25-10 30

Avenue

325 Park Avenue

Long Island City, NY 11102

Huntington, NY 11743

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: ________________________

Mail Out

Will Pick Up

1 – Medical Records Copy

2 – Patient Copy

MR-201

Revised 1/13

Patient Authorization For Release Of Medical Information To Third Party Form Page 2

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