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