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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)
ests, Operative Reports) Date Records to be disclosed do include do not include HIV-related information. (check one) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Att
at apply: I authorize Mount Sinai to disclose 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)
'S Date 12/14/2016 (Zip Code) Records to be disclosed do include do not include HIV-related information. (check One) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Att
apply: I authorize Mount Sinai to disclose medical information about my tZ Manhattan C 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 front to Admission Date(s) Discharge Date(s)
rts) NA R I 's Date 12/14/2016 Records to be disclosed do include do not include HIV-related information. (check one) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To 1Z Healthcare Provider O Insurance Company or Designee C At
Entities connected to both OPD Clinic and Alcohol and Drug Abuse