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PATIENT AUTHORIZATION for RELEASE of MEDICAL Mssm 2004
Long Island City NY 11102 For Mount Sinai Use Only Northshore Medical Group 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. By signing this authorization form I am authorizing the use or disclosure of my protected health information as described...
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