EFTA00313930.pdf

East Side Medico/ Radiology PLLC 170 East Ti Street - Lower Level New York, NY 10075 Phone Date AKI . rgIc) P1 Patient Last Name - S PSrgii First FFRE•`-) HOMO Addroso 9 E-As--r- Sff- SS I Nhavv egY- State JU op icca-I City cetattry lAS A Name Phone tin ___ Malik )C Female Data of Birth 01 - 52 IS» cSHLIVÄlt- Relationship tq3 3 Plien Ernen3ency Contact NS Name of Employer 772.14-r Cast (Ste) K QUART0- g SuIn ST.11OMAS WWI Employers Address 6100 Ra 140ö DMZ Primary Insurance Name Ire.1 > 1464 -114 0Ae C (.414 EPS-re-/A I Panty Holder Dateof an. 3-Arlae, 1153 Policy Holder Name re See fil;+ '[.; Policy a Phone Number of Insurance Company Secondary Insurance Name attleft Polley s Phone 0 of Secondary Insurance Company Policy Hader Dato of Birth Policy Holder Name ary to process the claim for services I authorized the release of any medical or other Information necess s or commercial Insurance benefit, to rendered to mo. I also request payment of government bonefitz myself or the party who accepts tho assignment below. Name CI E-6 7-1 2-Ci EI Signature Dato --5-4,1 fe,Qad or mod cal practice fot the sorvtces rendered. I authorize payment of medical benefits to tho physician Dato 703 I tra0 ig EFTA00313930