RADIOLOGY ASSOCIATES PAGE 61/82 10/85/2814 22:69 2122419987 LN Mount Sinai Atm: Geo PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient's Name: (Last) (First) (Middie) Unit Number; DOB: Tel.No,__/ / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Piease request/check all that apply: ACCESS REQUESTED U on-site inspection O record copy @ $.75/page Records Bil Date(s) of Service Documentis) C Entire Designated Record Set Oo —_—_ ee 0 Inpatient Visit(s) Oo GED Visit(s) o O Ambulatory Surgery o 0 Outpatient Clinic — Manhattan Oo i ent ° Q OCTA/CT SCAN 2 Dialysis a Q MRI-MRA | © IMA o H ; . Q ULTRA-SOUND | = Jack Martin o ; © NRC & Q) PET SCAN = OB/GYN o -RA { ° Pediatrics o Q x Y | © Psychiatry O Q) BONE DENSITY = Radiation Oncology o M { © Specialty Q MA MO 0 Outpatient Clinic Queens Go ; Q) CD - i" ° Family Health Associates 0 REP | © Senior Health Center o : Q ORT | ® Industrial Health Center o O pr CK UP | O FPA Practice/Provider. oO t] MAIL TO HOME , Q 7 Q i MAIL TO OTHER | O X-ray Films/Reports . ; 7m a 0 Pathology Slides/Reports o * O Other o MR-200 (Rev 1/13) EFTA00283622

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RADIOLOGY ASSDCIATES PAGE 82/62 10/85/2014 22:69 2122419987 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, | am requesting that Mount Sinai provide me with access to health information in the manner desc ribed above. | understand that | will be contacted if any fees for a summary or explanation may be charged for fulfilling this request, and that! will have an opportunity to modify or withdraw my request if | do not want to pay those fees, K Patient : *K Date: Signature Personal Representative PRINT NAME: Signature Authority: Date: Fe Address: No. Tel No. Seeger se {Personal Representative to sign only if patient is a minor or unable to sign on his/her own behalf}. Need By: ee Reason: __ eee Send completed form to the most appropriate area listed below: G Mount Sinai Hospital 0 FPA Patient Rights Coordinator Medical Records One Gustave L. Levy Place - Box 1081 One Gustave L. Levy Place — Box 1111 New York, NY 10029 New York, If. 10029 0) Mount Sinai Hospital Queens Q Northshore Medicat Group Medical Records Medical Records 25-10 30" Avenue 325 Park Avenue Huntington, NY Long Island City, NY 11102 Huntington, NY 11743 OG Other: = ee 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 (fF applicable); $ Name or Initials of Records Department Staff Member Processing This Request: es 0 Mail Out 0 Will Pick Up § 1- Medical Records Copy 2 - Patient Copy MR-200 (Rev 1/1 3) EFTA00283623