EFTA00313922.pdf

East Side Medical Radiology PLLC 170 East Tr3 Street - Lower Leval New York, MY 10075 Phone Date TA KI Igc)- 01 Ss? • Patine Lust Name e PS it 1 Prat Tref-TRC->) 9 eAs--r Home Address AO. City Niew VcieK— Mau N Zip 100-I Country LAs A Name Phone ..0 Cato of Birth &t 0- 57A sir pa Made Y_ Esmats Emergency Contact Mame iCAR4NA SHUOAIC Oblational* Plelq-klo pimps Name of Employer ouri-lo2n) TRiAs-r CAMP. (Sir.) Employers Address (oleo Ra 14O0K QUAD Su rre bai StilomAs kAti Printery Insurance Name Uhl treb HEAL:71-10.A€F: Dagoa Policy Noisier Name re enTrikI UMW Nett pM.W no SArta0, NYS Polley 0 era Phone Number of Insurance Company Secondary Insurance Name Policy is troupe Phone 0 of Secondary Insurance Company Paley Holder Name PoLicy Holder Date of BIM I authorized the release of any medical ar other I:donut:dim iterectelty to process the door for services rendered to me. I also request payment of government benefits or commercial Insurance benefits to mynelf or the party who accepts the assignment below. Marne C.Eter-1----ac-,-1 ET Eih. SIgnaturo Date TAN) 1 b> N2Ci I authorize payment of medical benefits to tho physician or mod cal practice for the services rendered. Nemo Signature Date EFTA00313922