01/15/2013 00:10 I tie DIU UM aata1 MOLird: Mount Hospital Sinai • Sinai of C&eens A nMakao allx1/-aunt Slit ReeptTal PATIENT A LESS REOV/E,ST FOR pito:0AL INFORMATION I ----- Attu: Georgette Smith Illi g elPPi i Records alli Fax No. Patient's Name: • (Last) (First) (Middle) Date of Unit Number: Birth: let. No. / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED. o on-efts inspection O record copy @ S.75/page Records • O Entire Designated Record Set 13 Inpatient Visit(s) CI ED Visit(s) ❑ Ambulatory Surgery O Outpatient Clinic— Manhattan b AHC Dialysis 0 IMA a Jack Martin NRC OBIGYN O Pediatrics 0 Psychiatry 0 Radiation Oncology 0 Specialty O Outpatient Clinic QUeens e Family Health Associates = Senior Health Center 0 Industrial Health Center ID FPA Practice/Provider. Bill Date(s) of Service Document(s) ❑ El ❑ o ❑ ❑ ❑❑ O 0 X-ray Filins/Repons El Pathology Slides/Reports ❑ Other ❑ O El ❑ . o MR-200 (3/03) 1- Medical Records Copy COOO1:1O1:3OOO1:3O CTA/CT SCAN MRI - MRA ULTRA-SOUND PET SCAN X-RAY BONE DENSITY MAMMO CD REPORT PICK UP MAIL TO HOME MAIL TO OTHER 4 , 2- Patient Copy EFTA00283624 01/15/2013 00:10 2122419987 PAGE 02/02 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 ff I do not want to pay those fees. * Patient 3if Date: Signature Personal Representative • PRINT NAME: Signature Authority: Date: . Address: Tel No. Need By: Reason: Send completed form to the most appropriate area listed below. ❑ Mount Sinai Hospital Medical Records One Gustave L. Levy Place — Box 1111 New York, N.Y. 10028 O Mount Sinai Hospital Queens Medical Records 25-10 3e Avenue Long Island City, NY 11102 O Other: O FPA Patient Rights Coordinator One Gustave L. Levy Place — Box 1061 New York, NY 10028 Northshore Medical Group Medical Records • Huntington, NY 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): 5 Name or Initials of Records Department Staff Member Processing This Request CI Mail Out O Will Pick Up 1- Medical Records Copy 2 - Patient Cdpy EFTA00283625