EFTA00316328.pdf

JEFP-REy Eps7Zi S -a5"7- 71_s1 r / Y i fi/ trivoitZ__ Yea An -lc OO L Modic_i e ct,L /14eao ss %e.t.a ; y I/81 Ea-sr 98fiC iv/7-4,6F, it %LA. /tje_cd 61.5-7z( EFTA00316328  Sheeran Qpreshi MD, MBA Mailingand Office Address Associate Professor, Orthopaedic Surgery Icahn School OF Medicine at Mount Sinai htuasiue Spinal Surgery 5 East 98th Street, 4th floor, Box 1188 Co-director, Spinal Surgery Fellowship New York, NY 10029-6574 The MountSinai Hospital 7 212.261.3909 F 646-537-8535 sheernz.tiurexhiemountsinakorg Spine Center February 20, 2017 Dear Patient, I am writing to inform you that on April 1, 2017, I am moving my practice to Hospital for Special Surgery. This is a new and exciting opportunity for me, and I hope that you will continue your care with me at my new location. Head of Minimally Invasive Spine Surgery at Hospital for Special Surgery East River Professional Building 523 East 72nd Street, 9th Floor New York, NY 10021 Office: (212) 606-1585 Fax: (917) 260-3185 Please be assured that my colleagues at The Spine Hospital at Mount Sinai, and Hospital for Special Surgery, are committed to providing you with excellent care. If you prefer to continue your care at The Spine Hospital at Mount Sinai, please call 212-241-8947. I recommend each of my colleagues highly. If you wish to continue care at my new practice, please complete the enclosed medical records release form and return to the designated address for processing. I want to thank you for allowing me to participate in your healthcare and for allowing me to be your physician. I wish you the best of health now and always and hope to see you in my new practice. Sincerely, Sheeraz A. Qureshi, MD EFTA00316329 a Mount Sinai PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient's Name: ,/ccr- PR a (Last) (First) (Middle) DOB: Of /' Z O/ 913 TeL No.: _ Month/Day/Year Pe.c c-/ VoRic- /OO1/ Address: :14- 7 / /L. / 61; Y (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED O record copy 5.75/page Records Date(s) of Service Document(s) El/Entire Designated Record Set O O Inpatient Visit(s) O O ED Visit(s) O ❑ Ambulatory Surgery O O Outpatient Clinic — Manhattan 0 0 Orthopaedics O O O O O FPA Practice/Provider. O O X-ray Films/Reports O O Pathology Slides/Reports O O Other ❑ Please complete other side tart Outestimalk10217tt p4. Sheeizaz aibees.41 NO. EFTA00316330