EFTA00283622.pdf

10/05/2014 22:09 2122419987 RADIOLOGY AqcrrIATES rIA.JC VAIVC An: Geo ' S Mount Sinai PATIENT ACCESS REQUEST FOR MED ICAL INFORMATION Patient's Name: (Last) (First) (Middle) Unit Number: DOB: Tel. No. / / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED ❑ on•site inspectio n ❑ record copy @ $.75/page Records Bill Date(s) of Service Document(s) ❑ Entire Designated Record Set ❑ ❑ inpatient Visit(s) ❑ ❑ ED Visit(s) ❑ ❑ Ambulatory Surgery ❑ ❑ Outpatient Clinic — Manhattan ❑ O AHC ❑ CTA/CT SCAN O Li O Dialysis ❑ O IMA MR1 - MRA ❑ = Jack Martin ❑ ULTRA-SOUND 0 NRC ❑ PET SCAN 0 OB/GYN ❑ CI LI O Pediatrics ❑ X-RAY O Psychiatry ❑ O Radiation Oncology BONE DENSITY ❑ O Specialty MAMMO ❑ Outpatient Clinic Queens lj COO CI ❑ O Family Health Associates CD ❑ O Senior Health Center ❑ REPORT o Industrial Health Center ❑ PICK UP ❑ FPA Practice/Provider: ❑ MAIL TO HOME ❑ X-ray Films/Reports MAIL TO OTHER ❑ ❑ Pathology Slides/Reports ❑ i ❑ Other ❑ MR-WO (Rev 1113) EFTA00283622 10/05/2014 22:09 2122419987 RADIOLOGY ACC IATES rNIL ULlyc We will not condition treatment or payment on whether you sign this authorization. we will riot release your records. However, if you refuse to sign PATIENT UNDERSTANDING AND SIGNATU RE By signing below, I am requesting that Mount Sinai provide me with access to described above. I understand that health information in the manner I will be contacted if any fees for a summary fulfilling this request, and that 1 will or have an opportunity to modify or withdraw my explanation may be charged for those fees. request if I do not want to pay Patient Signature Date: Personal Representative PRINT NAME: Signature Authority: Date: Address: {Personal Representative to sign only if Tel No. patient Is a minor or unable to sign on his/her own behalf).. Need By: Reason. Send completed form to the most appropriate area listed below: a Mount Sinai Hospital Medical Records 0 FPA Patient Rights Coordinator One Gustave L. Levy Place — Box One Gustave L. Levy Place — Box 1111 1061 New York,... 10029 New York, NY 10029 0 Mount Sinai Hospital Queens Medical Records Northshore Medical Group 25.10 30" Avenue Medical Records Long Island City, NY 11102 325 Park Avenue Huntington, NY Huntington, NY 11743 G Other For (Hospital) Use Only Date Received: (MO/DY/YR) Disposition of Request GRANTED DENIED PARTIALLY DENIED Patient Notified in Writing Of Respons e On This Date: (MO/DY/YR) / Fee Charged For Fulfilling This Request (if applicable): $ Name or Initials of Records Dep artment Staff Member Processi ng This Request: 17 Mail Out ❑ Will Pick Up 1- Medical Records Copy 2 - Patient Copy MR-200 (Rev 1/13) EFTA00283623