01/15/2013 00:10 I tie DIU UM aata1 MOLird: Mount Hospital Sinai • Sinai of C&eens A nMakao allx1/-aunt Slit ReeptTal PATIENT A LESS REOV/E,ST FOR pito:0AL INFORMATION I ----- Attu: Georgette Smith Illi g ielPPi alli eco Records Fax No. Patient's Name: • (Last) (First) (Middle) Date of Unit Number: Birth: let. No. / Month/Day/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: ACCESS REQUESTED. o on-efts inspection O record copy @ S.75/page Records • O Entire Designated Record Set 13 Inpatient Visit(s) CI ED Visit(s) K Ambulatory Surgery O Outpatient Clinic— Manhattan b AHC Dialysis 0 IMA a Jack Martin NRC OBIGYN O Pediatrics 0 Psychiatry 0 Radiation Oncology 0 Specialty O Outpatient Clinic QUeens e Family Health Associates = Senior Health Center 0 Industrial Health Center ID FPA Practice/Provider. Bill Date(s) of Service Document(s) K El K o K K KK O 0 X-ray Filins/Repons El Pathology Slides/Reports K Other K O El K . o MR-200 (3/03) 1- Medical Records Copy COOO1:1O1:3OOO1:3O CTA/CT SCAN MRI - MRA ULTRA-SOUND PET SCAN X-RAY BONE DENSITY MAMMO CD REPORT PICK UP MAIL TO HOME MAIL TO OTHER 4 , 2- Patient Copy EFTA00283624