Radiology i 1176 Fifth Avenue, MC Level Ne Yo | REQUEST FOR MOUNT SINAI RADIOLOGY/IMAGING RECORDS, including studies performed at Mount Sinai Radiology Associates © Dubin Breast Center Hess Center for Science & Medicine Center for Advanced Medicine 1176 Fifth Avenue, MC Level 1176 Fifth Avenue, First Floor 1470 Madison Avenue, SC2 level 5-17 East 102nd Street New York, NY 10029 New York, NY 10029 New York, NY 10029 New York, NY 10029 PATIENT FOR WHOM RECORDS ARE BEING REQUESTED: wpe Te! weecec! __ ERWwAeD _ ‘GE EAST Hi New Yoee _ AN 1002! ADDRESS ZIP CODE 0) 120 11953 DATE OF BIRTH MEDICAL RECORD NUMBER (F KNOWN) REGARDING THs RECORD REQUEST) Body part (e.g., be 1. aoCT/CTA oMRI/MRA o Ultrasound CEST = gee RL & TEST o PET o X-Ray o Bone Density NUCLCAR TEST 35017 ra = a Mammogram 9 Alr Recent vaeaniveon DEC.IS501 yeti ane IMAGING 2. aCT/CTA oMRI/MRA o Ultrasound o PET o X-Ray o Bone Density a Mammogram o 3. oCT/CTA oMRI/MRA o Ultrasound oPET o X-Ray o Bone Density o Mammogram o 4. oCT/CTA oMRI/MRA o Ultrasound oPET o X-Ray o Bone Density a Mammogram o DESTINATION (We will not condition treatment or payment on whether o Pickup you sign this authorization. However, if you refuse to sign we cannot release these records.) Mail (specify address/recipient if different from above) 8y signing below, | am requesting that Mount Sinai provide me with access to health information in the DE MOSKOJIT7Z. manner described on this form. | understand that | will RECIPIENT be contacted if any fees for a summary or explanation (4 ] NI FLA LER D2 S TE ADORESS FIOo fees. BEACH FL 3340) city STATE ZiP CODE MOUNT SINAI PROCESSING NOTES Return completed form (with any applicable fee) to: For a patient unable to sign on his/her own behalf, please Mail: Medical Records ES indicate authority under which this release is signed: Mount Sinai Radiology Associates : 1176 Fifth Avenue, MC Level o Parent o Guardian o Other: EFTA00313917