EFTA00313615.pdf

Mount Sinai N TO THIRD PARTY PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIO Patient s Name: Epstein Jeffrey (Last) (First) (Middle) Unit Number: Birth: Tel. No.: / ,2127509895 ntIVIDayNear Address 9 East 71st Street. New York. NY 10021 (State) (Zip Code) (Street) (DIY) Please request/check all that 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) Ambulatory Surgery Date Specify (i.e. Lab tests. Operative Reports) MR 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 O Healthcare Provider ❑ Insurance Company or Designee O Attorney O Court ❑ Law Enforcement O Employer Other Personal Assistant Name: Lesley Groff Address 9 East 71st Street, NY, NY 10021 Reason for Disclosure 0 Patient Request O Other if you refuse to sign we will not We will not condition treatment or payment on whether you sign this authorization. However. release your records. 1 — Medical Record Copy 2- Patient Copy MR-201 (REV 3/15) EFTA00313615