S Mount Sinai Department of Radiology Medical Records Office Mount Sinai Radiology Associates 1176 Fifth Avenue, MC Level New York, NY 10029 REQUEST FOR MOUNT SINAI RADIOLOGY/IMAGING RECORDS, including studies performed at MountStimi Raclobsy Associates Dubin Breast CatIlf Hess Center for Science & eledbine Cat lorMvarced Medicine 1176 Rh Mena, PAC Lad 1176 FM Avenue, First Atli 1470 Madsen kerue SC2 Wel 517 East 102nd Street ',6wYali nv 1CC29 s.ew von( s,C, 10129 Nek Yak NY loco NEW Yak, NY 10:Q9 PATIENT FOR WHOM RECORDS ARE BEING REQUESTED: 0,S- e/.1 LAST NAME q EAS-r 1- ADDRESS 01 /e7t / 1153 DATE OF BIRTH MEDICAL RECORD NUMBER (F KNOWN) Exam Type Body part (e.g., brain, left knee, etc.) Exam Date CD ($25) Paper Report 1. o CT/CTA o MRI/MRA 2 Ultrasound K PET K X-Ray K Bone Density K Mammogram / AUy peps= taT p.A.b LOt-)1 2. 2 CT/CTA c MRUMRA 0 Ultrasound o PET 2 X-Ray c Bone Density 2 Mammogram 0 3. n CT/CTA c MRUMRA 0 Ultrasound c PET 2 X-Ray c Bone Density Mammogram 0 CT/CTA c MRI/MRA 0 Ultrasound PET o X-Ray c Bone Density Mammogram K e 151; alniAgh NAME SOME NAME fJGw yore IA (p0aj H twit E ( OR QUESTIONS REGARDING THIS RECORD REQUEST) CES-IAAlf Pa TESr MLA( LCAP- -teSs-r IS vtpritA-ri-Ng_01 Ntm,tr4E-, 0 AUTHORIZATION i We will not condition treatment or payment on whether you sgn this authortadion. However, if you refuse to sign we cannot release these records.) By signing below, lam requesting that Mount Sinai provide me with access to health information in the manner described on this form. I understand that will be contacted if any fees for a summary or explanation may be charged for fulfilling this request, and that I will have the opportunity to modify to withdraw my request if I do not want to pay those fees. For a patient unable to sign on hisTher own behalf, please indicate authority under which this release is signed: Parent c Guardian 0 Other. DESTINATION Pickup Arbil (specify address/recipient if different from above) be. ttAosicoue) ILH 1 NI FL-A A LER -7 u CIF -i cso 'Al.pictc_IA &EA Of-) FL— 339-0) CITY STATE ZIP CODE MOUNT SINAI PROCESSING NOTES Return competed form (with any applicable fee) to: Mail: Medical Records Mount Sinai Radiology Associates 1 176 Fifth Avenue, MC Level Box 1235 New York NY 10029 EFTA00313917