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 O Will Pick Up
1 - Medical Records
https://www.justice.gov/epstein/files/DataSet%209/EFTA00306876.pdf