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MyChart Authorization for Use and Disclosure of Electronic Protected Health Information and Mount Sinai Medical Center Notice of Privacy Practices and MyChart Terms and Conditions of Use

The hospital's Notice of Privacy Practices can found under the Notice of Privacy Practices Section of this document. A paper copy of this document can be obtained by selecting the Terms and Conditions hyperlink after logging into MyChart and selecting the print icon.


  1. I authorize the use or disclosure of the above-named individual's electronic health information by Mount Sinai Medical Center to the "MyChart" Service, as indicated below.
  2. I understand that this authorization is for the purpose of allowing the MyChart© service to provide me and/or my authorized representatives, as well as caregivers involved in my medical care or treatment, with web-based access to the records of my medical care and/or treatment.
  3. I understand that the records subject to this authorization include any and all records which pertain to my diagnosis, treatment or care including, without limitation face sheet(s), history and physical examination(s), admission note(s), discharge summary(ies), radiology and laboratory testing, consultation report(s), progress notes, physicians' orders, medication/prescription records, operative and procedure notes, nursing notes, and similar records. I understand that this authorization will extend to medical records prepared or kept by third-party healthcare providers which are contained within the medical records of Mount Sinai.
  4. I understand that the records subject to this authorization may include (if applicable) information relating to sexually transmitted diseases ("STDs"), acquired immunodeficiency syndrome (HIV/AIDS); behavioral and mental health services (including communications with psychiatrists and psychotherapy notes), records of treatment for alcohol and substance abuse, and results of genetic (DNA) testing.
  5. I understand that any disclosure of health information carries with it the potential for an unauthorized re-disclosure, and that any information which is re-disclosed may not be protected by federal or state privacy laws. I hereby agree to release and hold Mount Sinai Medical Center harmless for complying in good faith with this Authorization.
  6. I understand that this authorization shall remain in effect until revoked. I understand that I have a right to revoke this authorization at any time, except to the extent that action has been taken by Mount Sinai Medical Center in reliance on it. Patients may request deactivation of an account by sending an e-mail to our MyChart Support Staff at and be sure to include your phone number and contact information. It is understood that any such revocation will not be effective until received by the MyChart Support Staff at Mount Sinai Medical Center.
  7. I understand that this authorization is voluntary, and that my refusal to sign this authorization will not affect my eligibility for health care services or treatment in any way.
  8. I understand that my use of the MyChart© service is subject to the Terms and Conditions and other restrictions which apply to the use of that service as published on the website, .
  9. Notice of Privacy Practices

    Effective Date: January 25, 2013

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact the Facility Privacy Official by dialing 305-674-2722.

    THIS NOTICE COVERS Mount Sinai Medical Center provides health care to patients jointly with physicians and other health care professionals and organizations. Mount Sinai Medical Center and the individual described below together are sometimes called "us" or "we" in this Notice. The privacy practices described in this Notice apply to all impatient and outpatient departments, units and programs of Mount Sinai Medical Center, whether located on or off the main campus of the hospital, and will be followed by all employees, staff, trainees, students, volunteers and other hospital personnel who have a need to use your health information to perform their job, including physician members of the medical staff and allied health professional while they are caring for you in the hospital. The individuals described above may share your health information with each other to carry out treatment, payment, or health care operation related to your care. This Notice explains generally how this hospital and the individuals described above might share or disclose your health information. This Notice does not cover services provided in the private offices of physicians.

    UNDERSTANDING YOUR HEALTH RECORD/INFORMATION Each time you visit a hospital, physician, or other healthcare Provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

    • Basis for planning your care and treatment.
    • Means of communication among the many health professionals who contribute to your care.
    • Document describing the care you received.
    • Means by which you or a third-party payer can verify that services billed were actually provided.
    • A tool in educating health professionals.
    • A source of data for medical research.
    • A source of information for public health officials charges with improving the health of the nation.
    • A source of data for facility planning and marketing.
    • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
      Understanding what is in your record and how your health information is used helps you to:
    • Ensure its accuracy.
    • Better understanding who, want, when, where, and why others may access your health information.
    • Make more information decisions when authorizing disclosure to others.

    YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

    • Request a restriction on certain users and disclosures of your information as provided by 45 CFR 164.522
    • Obtain a paper copy of the notice of information practice upon request
    • Inspect and copy your health record as provided for in 45 CFR 164.528
    • Amend your health record as provided in 45 CFR 164.528
    • Request communications of your health information by alternative means or at alternative locations
    • Request that we restrict certain disclosures of information in your health record to your health plan with respect to health care items or services for which you, or someone other than your health plan, have paid in full
    • Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

    OUR RESPONSIBILITIES This organization is required to:

    • Maintain the privacy of your health information.
    • Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
    • Abide by the terms of this notice.
    • Notify you if we are unable to agree to a requested restriction.
    • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
    • Notify you in the event that it has been determined that a breach of the privacy of your health information has occurred.
    • Not disclose psychotherapy notes which are maintained by us without your authorization.
    • Not disclose your health information under circumstances which would constitute a sale of such information under 45 CFR 164.508(a)(4) without your authorization.
    • Not disclose your health information for marketing purposes without your authorization.
    • Although we may change our practices and to make the new provisions effective for all protected health information we maintain, if we do change our information practice we will post a revised copy on our facility web site. We will not use or disclose your health information without your authorization, except as described in this notice.

    FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions and would like additional information, you may contact the Director of Health Information Management at 305-674-2320. If you believe your privacy rights have been violated, you can file a complaint by contacting the Privacy Officer at 305-674-2722, or with the Secretary of Health and Human Services, Office of Civil Rights. There will be no retaliation for filing a complaint.

    EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS We will use your health information for treatment. For Example: Information obtained by a nurses, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physicians will document in your record his or her expectations of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies various reports that should assist him or her in treating you once you're discharge from this hospital. We will use your health information for payment. For Example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as, your diagnose, procedures, and supplies used. We will use your health information for regular health care operations. For Example: Members of the medical staff, our risk or quality improvement manager, or members of our quality improvement team may use information in your health record to assess the care and outcomes in your case and other like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide. Business Associates: There are some services provided in our organization through contracts with business associates who create, receive, maintain, or transmit protected health information on our behalf. Examples include certain laboratory tests and transcription services. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we've asked them to do and, if appropriate, bill you or your third-party payer for service rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information as specified by a contract that provides the information will be kept confidential. Business Decision Making: We may combine medical information about many hospital patients in an overview to decide what additional services the hospital should offer, what service are not needed, and whether certain new treatments are effective. We also may disclose information to physicians, nurses, technicians, medical students, and other personnel for review and education. We may combine the medical information we have with medical information from other facility to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. Directory: Unless you notify us that you are object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person who is responsible for you care, of your location and general condition. Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friend or any other person you identify, health information to the extent that it is relevant to that person's involvement in your care or payment related to your care. Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health record. Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties. Organ Procurement Organizations: Consistent with applicable law, we many disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Fund Raising: We may contact you as part of a fundraising effort. Your demographic data and dates of service may be provided to our institutionally related foundation for this purpose. You have the right to opt out of receiving such fundraising communications. Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement. Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker compensation or other similar programs established by law. Public Health: As required by law, we may disclose your health information to legal authorities charged with preventing or controlling disease, injury, or disability. Correctional Institution: Should you be inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. Law Enforcement: we may disclose health information for enforcement purpose as required by law or in response to valid subpoena. Federal law provides that an appropriate health oversight agency, public health authority or attorney may have access to your health information if a work force member or business associate believes in good faith that we have engages in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

    MOUNT SINAI MEDICAL CENTER 4300 Alton Road Miami Beach, Florida 33140

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    MyChart Terms and Conditions of Use

    Mount Sinai Medical Center in Miami Beach, FL and affiliated Physician Medical Offices are pleased to offer you access to certain health-related information via a Web-based version of our computer systems called MyChart©.

    OVERVIEW: Mount Sinai Medical Center MyChart© is an internet-based service that allows patients to access certain personal medical information online. MyChart© is not the complete copy of the legal medical record. This is a voluntary service, offered as a convenience and courtesy by Mount Sinai Medical Center to our patients who have recently been discharged or currently receive care from one of our Mount Sinai Medical Center Physicians. Mount Sinai Medical Center reserves the right to revoke or limit access to the MyChart© service at any time for any reason and without notice.

    PRIVACY: Your privacy is of the utmost importance to us. Mount Sinai Medical Center will use your confidential medical information in order to provide you healthcare services. Healthcare Providers will, at all times, maintain your confidential medical information in strict confidence and will not disclose any information regarding you to any unaffiliated third party, unless you authorize that person to receive your information or the information is permitted or required to be disclosed by law. Please review Mount Sinai Medical Center's Notice of Privacy Practices for a thorough description of how we gather, use and protect your confidential medical information.

    NOT MEDICAL ADVICE: NON-EMERGENCY ONLY: The MyChart© service is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Mount Sinai Medical Center MyChart© services should never be used for emergencies or urgent needs. Patients experiencing a life-threatening emergency should call 911. Patients with urgent needs should call Mount Sinai Medical Center or their personal healthcare provider for assistance.

    MINOR ELIGIBILITY: An individual must be age 18 or older to request a personal account.

    DEACTIVATION: Participation in Mount Sinai Medical Center MyChart© is voluntary. Patients may request deactivation of an account by sending an e-mail to our MyChart Support Staff at and be sure to include your phone number and contact information. You will then be contacted by phone by our MyChart Support Staff who will assist with deactivation. Mount Sinai Medical Center reserves the right to deactivate or prevent a patient's access to any or all Mount Sinai Medical Center MyChart© features at any time for any reason and without notice.

    PROTECTING LOGIN INFORMATION: Patients who wish to participate will be issued a MyChart activation code upon discharge or during their Physician's office visit. The activation code is used to gain first-time access, at which time a permanent username and password are created by the patient. It is extremely important that patients keep the activation code, username and password confidential. Anyone with access to this information will be able to access the patient's Mount Sinai Medical Center MyChart© account at Mount Sinai Medical Center accepts no responsibility for unauthorized access to a patient's medical information resulting from lost, stolen or misused activation codes, usernames or passwords.

    PROTECTED HEALTH INFORMATION: Mount Sinai Medical Center's MyChart© service includes the capability to receive personally identifiable health information which is protected by federal and other law. Your use of the MyChart© service constitutes your express authorization for Mount Sinai Medical Center to disclose identifiable health information to your designated MyChart© account for the purposes described here. Patients may revoke their authorization and discontinue their account by contacting our MyChart Support Staff at (305) 674-2545 during the hours of 8am to 5pm and listen for the MyChart prompt. After hours, send an e-mail to and be sure to include your contact information. Revocation of your authorization or discontinuance of your MyChart© account will not affect your medical care in any way. Mount Sinai reserves the right to disclose or to re-disclose such information as required or permitted by law.

    EMAIL NOTIFICATION: Patients who are users of MyChart© will be notified via email when there is new information to be viewed on MyChart. This means that any person with access to a patient's email will be able to see this notification. This could include the patient's spouse, employer or anyone else that can access a patient's email account. Although no private medical information will be sent, the notification that new medical information is available by accessing MyChart may be information that a patient would not want others to know. By providing an email address in connection with the MyChart© service, you expressly consent to email notification by the MyChart© service when there is new information to be viewed in MyChart©.

    SECURE MESSAGING: Mount Sinai Medical Center MyChart© allows users to send and receive secure electronic messages with providers who are active with Mount Sinai Medical Center MyChart©. Due to technical factors, the availability of appropriate staff and other circumstances, Mount Sinai Medical Center cannot guarantee that messages from users will receive a timely response. Messages regarding medical issues may become part of the patient's permanent medical record, and will be available to those who participate in the patient's care and treatment in the future. As with any information contained in the medical record, Mount Sinai reserves the right to disclose or to re-disclose such information as required or permitted by law.

    WEBSITE LINKS: MyChart© may offer links to related medical or other websites not managed by Mount Sinai Medical Center. These website link(s) are for a patient's informational purposes only. Mount Sinai Medical Center does not endorse, and has not verified the accuracy of, the information in/on these websites, and the patient should not rely on any of the information found on the websites for purposes of treatment or diagnosis. WEBSITE CHANGES AND AVAILABILITY: Mount Sinai Medical Center may revise, change or update the Mount Sinai Medical Center MyChart© website periodically. The website may not always be available due to system maintenance, backups or failures.

    USE OF THIRD-PARTY SERVICES: You may choose to use other services provided by third parties in conjunction with your use of MyChart. Such services may include, but are not limited to, translation services, location services, and other third-party offerings. Any links to such services are provided for your convenience only. Neither Epic nor Mount Sinai Medical Center have control over the contents of these services, and neither Epic nor Mount Sinai Medical Center accept any responsibility for them or for any loss or damage that may arise from your use of them. Such services may require you to submit your information to a third party, which may result in a copy of your information be used and/or stored by a third party. If you decide to access any such services in conjunction with your use of MyChart, you do so entirely at your own risk and subject to the terms and conditions of use for such services.

    ACCURACY AND INTEGRITY OF INFORMATION When using the MyChart© service, information will be transmitted over a medium that may be beyond the control of Mount Sinai Medical Center. Accordingly, Mount Sinai Medical Center assumes no liability for or relating to the delay, failure, interruption, or corruption of any data or other information transmitted in connection with use of the MyChart© service. Although Mount Sinai Medical Center attempts to ensure the integrity of the MyChart© website, it makes no guarantees whatsoever as to the correctness or accuracy of the Site. It is possible that the Site could include typographical errors, inaccuracies or other errors. In the event that an inaccuracy arises, please inform your Healthcare Providers so that it can be corrected. Information contained on the Site may be changed or updated without notice.

    Mount Sinai Medical Center reserves the right to modify this Agreement at any time. Any modifications will become effective immediately upon posting to the Site. You agree that it is your responsibility to review the Agreement periodically to be aware of such modifications, as your continued access or use of the Site shall be deemed your conclusive acceptance of the modified Agreement.

    Portions of the materials on this website © 2010 Mount Sinai Medical Center of Florida. © 1999-2006 Epic Systems Corporation. U.S. Patent 5,301,105. Other U.S. and international patents pending. MyChart, Epic, Powered by Epic; and the MyChart logo are trademarks of Epic Systems Corporation