Form Mr 201 is a tax form used to report the sale or exchange of certain Partnership interests. This form is used to report the information of the buyer and seller, as well as the partnership's ID number. Form Mr 201 must be filed within thirty days of the sale or exchange transaction. This form is extremely important for any individual involved in a partnership sale or exchange, as it provides detailed information on how to report the transaction correctly. Understanding and completing this form properly can help avoid any penalties from the IRS. Make sure you consult with a tax professional if you have any questions!
| Question | Answer |
|---|---|
| Form Name | Form Mr 201 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Huntington, mr 201 form, HIV, Sinai |
PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY
Patient’s
Name: _____________________________________________________________________________________
(Last) |
(First) |
(Middle) |
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Date of |
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Unit Number: ________________ |
Birth: __________________ |
Tel. No.:___/_____/___________ |
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Month/Day/Year |
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Address: ____________________________________________________________________________________
(Street) |
(City) |
(State) |
(Zip Code) |
Please request/check all that apply:
I authorize Mount Sinai to disclose medical information about my:
o Manhattan o Queens o Huntington
___Emergency Room visit on: __________________________________________________
Date(s)
___OPD Clinic visit, specify clinic: _______________________________________________
Date(s)
___FPA Practice/Provider_______________________________________________________
Name of ProviderDate(s)
___ Hospitalization from: __________________________ to __________________________
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Admission Date(s) |
Discharge Date(s) |
___ Ambulatory Surgery: |
Date: ________________________ |
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____Specify (i.e. Lab tests, Operative Reports)______________________________ Date____________
Records to be disclosed ____ do include ____ do not include HIV
To o Healthcare Provider |
o Insurance Company or Designee |
o Attorney |
|
o Court |
o Law Enforcement |
o Employer |
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Other: _______________________________________________________________________
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Reason for Disclosure o Patient Request |
o 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 |
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
If I am authorizing the release of
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 |
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Signature: ___________________________________ |
Date: ___________________________________ |
Personal Representative |
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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 |
Huntington, NY |
|
Long Island City, NY 11102 |
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For Mount Sinai Use Only |
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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 |
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1 – Medical Records Copy |
2 – Patient Copy |
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