EFTA00313615.pdf

Mount Sinai PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY Patient s Name: Epstein Jeffrey (Last) (First) Unit Number: Birth: (Middle) Tel. No.: ntIVIDayNear / ,2127509895 Address 9 East 71st Street. New York. NY 10021 (Street) (DIY) (State) 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 (Zip Code) 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 K Insurance Company or Designee O Attorney O Court K Law Enforcement Other Personal Assistant Name: Lesley Groff Address 9 East 71st Street, NY, NY 10021 O Employer Reason for Disclosure 0 Patient Request O Other 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. 1 — Medical Record Copy 2- Patient Copy MR-201 (REV 3/15) EFTA00313615