10/05/2014 22:09 2122419987 RADIOLOGY AqcrrIATES rIA.JC VAIVC An: Geo ' S Mount Sinai PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient's Name: (Last) (First) (Middle) Unit Number: DOB: Tel. No. / / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED ❑ on•site inspection ❑ record copy @ $.75/page Records Bill Date(s) of Service Document(s) ❑ Entire Designated Record Set ❑ ❑ inpatient Visit(s) ❑ ❑ ED Visit(s) ❑ ❑ Ambulatory Surgery ❑ ❑ Outpatient Clinic — Manhattan ❑ O AHC ❑ O Dialysis ❑ O IMA = Jack Martin ❑ ❑ 0 NRC ❑ 0 OB/GYN ❑ O Pediatrics ❑ O Psychiatry ❑ O Radiation Oncology ❑ O Specialty ❑ Outpatient Clinic Queens O Family Health Associates O Senior Health Center o Industrial Health Center ❑ ❑ ❑ ❑ ❑ FPA Practice/Provider: ❑ ❑ ❑ X-ray Films/Reports ❑ Pathology Slides/Reports ❑ ❑ Other ❑ MR-WO (Rev 1113) lj COO CI CI LI O Li CTA/CT SCAN MR1 - MRA ULTRA -SOUND PET SCAN X-RAY BONE DENSITY MAMMO CD REPORT PICK UP MAIL TO HOME MAIL TO OTHER i EFTA00283622 10/05/2014 22:09 2122419987 RADIOLOGY ACC IATES rNIL ULlyc We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign we will riot 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 1 will have an opportunity to modify or withdraw my request if I do not want to pay those fees. Patient Date: Signature Personal Representative PRINT NAME: Signature Authority: Date: Address: Tel No. {Personal Representative to sign only if patient Is a minor or unable to sign on his/her own behalf).. Need By: Reason. Send completed form to the most appropriate area listed below: a Mount Sinai Hospital Medical Records One Gustave L. Levy Place — Box 1111 New York,... 10029 0 Mount Sinai Hospital Queens Medical Records 25.10 30" Avenue Long Island City, NY 11102 G Other 0 FPA Patient Rights Coordinator One Gustave L. Levy Place — Box 1061 New York, NY 10029 Northshore Medical Group Medical Records 325 Park Avenue Huntington, NY Huntington, NY 11743 For (Hospital) Use Only Date Received: (MO/DY/YR) Disposition of Request GRANTED DENIED Patient Notified in Writing Of Response On This Date: (MO/DY/YR) / Fee Charged For Fulfilling This Request (if applicable): $ Name or Initials of Records Department Staff Member Processing This Request: PARTIALLY DENIED 17 Mail Out 1- Medical Records Copy ❑ Will Pick Up 2 - Patient Copy MR-200 (Rev 1/13) EFTA00283623