Form Mr 201 PDF Details

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!

Form NameForm Mr 201
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesHuntington, mr 201 form, HIV, Sinai

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Name: _____________________________________________________________________________________





Date of



Unit Number: ________________

Birth: __________________

Tel. No.:___/_____/___________





Address: ____________________________________________________________________________________




(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: __________________________________________________


___OPD Clinic visit, specify clinic: _______________________________________________


___FPA Practice/Provider_______________________________________________________

Name of ProviderDate(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)

To o Healthcare Provider

o Insurance Company or Designee

o Attorney

o Court

o Law Enforcement

o Employer

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

MR-201 (Rev 5/04)

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.


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.



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

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 30th 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): $ ________________

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 (Rev 5/04)