EFTA00520746.pdf

Radiology Breast Imaging Request Mount Dubin Breast Center Sinai o the TezhciwAr Instluto Patients Name: First: MRN: DOB: Telephone Number: Address: Dubin Breast Center, Radiology Department Tel.: Option 1, Option 3 FAX: Film Libra Tel.: FAX: Last: Middle Records Requested Dates of Service K Imaging Reports Only K Imaging on a CD — Digital copy of images on a disc K Imaging printed on Film - Photographic hard copy film K All on file K Specific Date Range: K Specific Date: K All on file K Specific Date Range: K Specific Date: K All on file K Specific Date Range: K Specific Date: Exam Type If you are requesting images for a physician to review then please check with the physician's office on the kind of imaging format they prefer, CD or film. EFTA00520746 We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign we will not release your records. Patient Understanding Signature By signing below, I am requesting that Mount Sinai provide me with access to health information in the manner described above. I understand that I will be contacted if any fees as a summary or explanation may be charged for fulfilling this request, and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees. Patient Signature Date: Personal Representative: Print Name: Authority: Date: Send To - Include Name of Receiver, Full Address Including Zip Code, and FAX number If applicable: Imaging with report to be: Mail Out to Above Address Pick Up At Dubin Breast Center Welcome Desk —1176 5th Ave, First Floor, Cross Street 98th Street, New York, NY, 10029 CI At Radiology Associates Film Library — Mount Sinai Hospital, Radiology Associates Film Library, 1468 Madison Ave., Cross Street 100th Street, MC Level, Main Corridor, New York, NY 10029 K FAX Reports to the Above Fax Number For (Hospital) Uso Only Date Received: (MO/DWYR) Disposition of Request: GRANTED DENIED PARTIALLY DENIED Patient Notified hi Writing Of Response On This Date: (M0IDY/YR) Fee Charged For FullIling This Request (if applicable): Name or Initials of Records Department Slafl Member Processing This Request: EFTA00520747