Mount Sinai PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY Patient's Name: (Last) (First) (Middle) Date of Unit Number: Birth: Tel. No.: / MontIVDay/Year Address: (Street) (City) (State) (Zip Code) Please request/check all that apply: I authorize Mount Sinai to disclose medical information about my: K Manhattan K Queens K 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) Date 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 K Court K Law Enforcement K Employer Other: Name: Address: Reason for Disclosure K Patient Request K 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) EFTA00306876