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)

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)

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)