10/05/2014 22:09 2122419987 RADIOLOGY AqcrrIATES rIA.JC VAIVC An: Geo ' S Mount Sinai PATIENT ACCESS REQUEST FOR MEDICAL 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 K on•site inspection K record copy @ $.75/page Records Bill Date(s) of Service Document(s) K Entire Designated Record Set K K inpatient Visit(s) K K ED Visit(s) K K Ambulatory Surgery K K Outpatient Clinic — Manhattan K O AHC K O Dialysis K O IMA = Jack Martin K K 0 NRC K 0 OB/GYN K O Pediatrics K O Psychiatry K O Radiation Oncology K O Specialty K Outpatient Clinic Queens O Family Health Associates O Senior Health Center o Industrial Health Center K K K K K FPA Practice/Provider: K K K X-ray Films/Reports K Pathology Slides/Reports K K Other K MR-WO (Rev 1113) lj COO CI CI LI O Li CTA/CT SCAN MR1 - MRA ULTRA-SOUND PET SCAN X-RAY BONE DENSITY MAMMO CD REPORT PICK UP MAIL TO HOME MAIL TO OTHER i EFTA00283622