EFTA00313917.pdf

Medical Records Office S Mount Mount Sinai Radiology Associates Sinai 1176 Fifth Avenue, MC Level Department ofRadiology New York, NY 10029 REQUEST FOR MOUNT SINAI RADIOLOGY/IMAGING RECORDS, including studies performed at MountStimi Raclobsy Associates Dubin Breast CatIlf Hess Center for Science & eledbine Cat lorMvarced Medicine 1176 RhMena, PAC Lad 1176 FM Avenue, First Atli 1470 Madsen kerue SC2 Wel 517 East 102nd Street ',6wYali nv 1CC29 s.ew von( s,C, 10129 Nek Yak NY loco NEW Yak, NY 10:Q9 PATIENT FOR WHOM RECORDS ARE BEING REQUESTED: 0 , S- e/.1 eNAME 151; alniAgh LAST NAME SOME NAME q EAS-r ADDRESS 1- fJGw yore IA (p0aj 01 /e7t / 1153MEDICAL RECORD NUMBER DATE OF BIRTH H twit E ( OR QUESTIONS (F KNOWN) REGARDING THIS RECORD REQUEST) Body part (e.g., CD Paper Exam Type Exam Date brain, left knee, etc.) ($25) Report 1. o CT/CTA o MRI/MRA 2 Ultrasound CES-IA Alf Pa TESr ❑ PET ❑ X-Ray ❑ Bone Density MLA( LCAP- -teSs-r ❑ Mammogram / AUy taT peps= vtpritA-ri-Ng_01 IS p.A.b LOt-)1 2. 2 CT/CTA c MRUMRA 0 Ultrasound Ntm,tr4E-, o PET 2 X-Ray c Bone Density 0 2 Mammogram 0 3. n CT/CTA c MRUMRA 0 Ultrasound c PET 2 X-Ray c Bone Density Mammogram 0 CT/CTA c MRI/MRA 0 Ultrasound PET o X-Ray c Bone Density Mammogram ❑ AUTHORIZATION DESTINATION i We will not condition treatment or payment on whether Pickup you sgn this authortadion. However, if you refuse to sign we cannot release these records.) Arbil (specify address/recipient if different from above) By signing below, lam requesting that Mount Sinai provide me with access to health information in the be. ttAosicoue) manner described on this form. I understand that will be contactedif any fees for a summary or explanation may be charged for fulfilling this request, and that I ILH 1 NI FL-A A LER -7u CIF will have the opportunity to modify to withdraw my -i cso requestif I do not want to pay those fees. 'Al.pictc_IA &EA Of-) FL— CITY STATE 339-0) ZIP CODE MOUNT SINAI PROCESSING NOTES Return competed form (with any applicable fee) to: For a patient unable to sign on hisTher own behalf, please Mail: Medical Records indicate authority under which this release is signed: Mount Sinai Radiology Associates 1176 Fifth Avenue, MC Level Parent c Guardian 0 Other. Box 1235 New York NY 10029 EFTA00313917