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apply: I authorize Mount Sinai to disclose medical information about my: K Manhattan K Queens K Huntington _Emergency Room visit on: Date(s) _OPD Clinic visit. specify clinic: Date(s) FPA Practice/Provider Name of Provider Date(s) Hospitalization from: to Admission Date(s) Discharge Date(s)

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e medical information about my. 0 Manhattan O Queens O Huntington Emergency Room visit on. Date(s) OPD Clinic visit. specify clinic: Date(s) FPA Practice/Provider Name of Provider Date(s) Hospitalization from: to Admission Date(s) Discharge Date(s) Ambulatory Surgery Date Specify (i.e. Lab tests. Ope

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