Radiology Breast Imaging Request IX Dubin Breast a: Radiology Department Mount Dubin Breast Center Tel.: Option 1, Option 3 Sinai olthe Tisch Cancer Ina tute FAX: Film Libra FAX: Patients Name: First: Last: Middle MRN: DOB: Telephone Number: Address: | Exam Type Dates of Service | Records Requested DD alionfile DD imaging Reports Only oO Specific Date Range: oO Specific Date: a) imaging ona CD — CO) allonfile ' Digital copy of images ona disc C Specific Date Range: o Specific Date: | (7) imaging printed on Film - DC ation file | Photographic hard copy film 1 Specific Date Range: 0 Specific Date: If you are requesting images for a physician to review then please check with the physician’s office on the kind of imaging format they prefer, CD or Film. EFTA00520746

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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 Signature By signing below, | am requesting that Mount Sinai provide me with access to health information in the manner described above. | understand that | will be contacted if any fees as 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. Patient Signature. Date: Personal Representative: Print Name: Authority: Date: Send To - Include Name of Receiver, Full Address including Zip Code, and FAX number if applicable: f) Imaging with report to be: Oo Mail Out to Above Address im Pick Up oO At Dubin Breast Center Welcome Desk — 1176 5" Ave, First Floor, Cross Street 98" Street, New York, NY, 10029 oO *t Radiology Associates Film Library —- Mount Sinai Hospital, Radiology Associates Film Library, 1468 Madison Ave., Cross Street 100" Street, MC Level, Main Corridor, New York, NY 10029 0 FAX Reports to the Above Fax Number For (Hospital) Use Only Date Received: (MO/DY/YR) / Disposition of Request: GRANTEO DENIED PARTIALLY DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) i 1 Fee Charged For Fulfiling This Request (if applicable): $ Name of Initials of Records Department Staff Member Processing This Request: EFTA00520747