This document is a patient authorization form from Mount Sinai for the release of medical information to a third party. It includes options for the type of information to be disclosed, such as emergency room visits, clinic visits, hospitalizations, and specific medical records. The form also addresses the inclusion of sensitive information like HIV-related, alcohol and drug abuse, and psychiatric records. It outlines the patient's rights regarding the disclosure and the process for revoking authorization. The form is incomplete with many fields left empty, including patient details and signatures.
documents/EFTA00306876.pdf
{}