EFTA00313618.pdf

Mount Sinai PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY Patients Name: Epsteir Jeirey (Last) (First) (Middle) Unit Number: BARNS_ Tel. No.: / I 2127509895 Month/Day/Year Address: 9 Fast 7' St Street. New York, NY 10O21 (Street) (City) (State) Please request/check all that apply: I authorize Mount Sinai to disclose medical information about my tZ Manhattan C 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 front to Admission Date(s) Discharge Date(s) Ambulatory Surgery Date (Zip Code) _Specify (i.e. Lab tests. Operative Reports) NA R 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 1Z Healthcare Provider O Insurance Company or Designee C Attorney K Court O Law Enforcement Other: Name: Dr. Bruce Moskowitz Address. 1411 N. Flagler Dr, Suite 7100, West Palm Beach. FL 33401 O Employer Reason for Disclosure 2 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) EFTA00313618