Mount Sinai Medical Form PDF Details

Access to medical records is an essential aspect of managing one’s health efficiently. The Mount Sinai Medical form serves as a critical tool for patients wishing to request access to their medical information, whether for personal use, for a caregiver, or perhaps for transferring records to another healthcare provider. This comprehensive form allows patients to specify the type of access they require, such as on-site inspection or copies of records at a nominal fee per page. It covers a wide range of medical documents, including the entire designated record set, inpatient, Emergency Department (ED) visits, ambulatory surgery, outpatient clinics across various specialties, and more unique requests like X-ray films/reports or pathology slides/reports. What stands out is the form’s acknowledgment that treatment or payment cannot be conditioned on the signing of this authorization, reassuring patients of their rights. Furthermore, it outlines the procedures for those acting as personal representatives for minors or incapacitated individuals. The clear statement that fees may be applied for the provision of summaries or explanations, with the guarantee of prior notification, ensures transparency. This form is directed to specific areas within the Mount Sinai health system, including both main hospitals and specialized clinics, to streamline the process. The provision for denying or partially denying requests with a notification obligation highlights the procedural fairness imbued in the process. Ultimately, the form represents a well-structured process facilitating patient rights to access their medical records while ensuring compliance with healthcare regulations.

QuestionAnswer
Form NameMount Sinai Medical Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaccess request medical form, mount sinai information, mr 200 form, access request medical

Form Preview Example

PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION

Patient’s

Name:

 

(Last)

(First)

 

 

(Middle)

 

 

 

 

 

 

 

 

 

Unit Number:

DOB:

 

 

 

Tel. No.

/_

/_

 

 

 

 

 

 

 

 

 

Month/Day/Year

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street)

(City)

 

 

(State)

 

 

 

 

 

(Zip Code)

Please request/check all that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCESS REQUESTED on-site inspection

record copy @ $.75/page

 

 

 

 

 

 

 

 

 

Records

 

Bill

Date(s) of Service

 

 

Document(s)

Entire Designated Record Set

 



 

 

 

 

 

 

 

 

 

 

 

 

Inpatient Visit(s)

 



 

 

 

 

 

 

 

 

 

 

 

 

ED Visit(s)

 



 

 

 

 

 

 

 

 

 

 

 

 

Ambulatory Surgery

 



 

 

 

 

 

 

 

 

 

 

 

 

Outpatient Clinic – Manhattan

 



 

 

 

 

 

 

 

 

 

 

 

 

AHC

 



 

 

 

 

 

 

 

 

 

 

 

 

Dialysis

 



 

 

 

 

 

 

 

 

 

 

 

 

IMA

 



 

 

 

 

 

 

 

 

 

 

 

 

Jack Martin

 



 

 

 

 

 

 

 

 

 

 

 

 

NRC

 



 

 

 

 

 

 

 

 

 

 

 

 

OB/GYN

 



 

 

 

 

 

 

 

 

 

 

 

 

Pediatrics

 



 

 

 

 

 

 

 

 

 

 

 

 

Psychiatry

 



 

 

 

 

 

 

 

 

 

 

 

 

Radiation Oncology

 



 

 

 

 

 

 

 

 

 

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Outpatient Clinic Queens

 



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family Health Associates

 



 

 

 

 

 

 

 

 

 

 

 

 

Senior Health Center

 



 

 

 

 

 

 

 

 

 

 

 

 

Industrial Health Center

 



 

 

 

 

 

 

 

 

 

 

 

 

FPA Practice/Provider:

 



 

 

 

 

 

 

 

 

 

 

 

 

X-ray Films/Reports



Pathology Slides/Reports



Other



MR-200 (Rev 1/13)

 

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.

PATIENT UNDERSTANDING AND SIGNATURE

By signing below, I am requesting that Mount Sinai provide me with access to health information in the manner described above. I understand that I will be contacted if any fees for a summary or explanation may be charged for fulfilling this request, and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees.

Patient

 

 

 

 

 

Date:

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

Personal Representative

 

 

 

 

 

PRINT NAME:

 

 

 

 

 

 

Signature

 

Authority:

 

 

 

 

 

Date:

 

 

 

Address:

 

 

 

 

 

Tel No._

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

{Personal Representative to sign only if patient is a minor or unable to sign on his/her own behalf}.

Need By:

 

Reason:

Send completed form to the most appropriate area listed below:

Mount Sinai Hospital

 

 

 

 

 

FPA Patient Rights Coordinator

Medical Records

 

 

 

 

 

One Gustave L. Levy Place – Box 1061

One Gustave L. Levy Place – Box 1111

New York, NY 10029

 

 

 

 

 

 

 

 

New York, N.Y. 10029

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mount Sinai Hospital Queens

 

 

 

Northshore Medical Group

 

 

 

 

 

Medical Records

 

 

 

 

 

Medical Records

 

 

 

 

 

 

 

 

25-10 30th Avenue

 

 

 

 

 

325 Park Avenue Huntington, NY

Long Island City, NY 11102

 

 

 

Huntington, NY 11743

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For (Hospital) 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-200 (Rev 1/13)

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