EFTA00313969.pdf

EAST RIVER .MEDICAL IMAGING. PC SIGNATURE ON FILE/INSURA NCE AUTHORIZATION CARD I AUTHORIZE USE OF THIS FORM FOR ALL MY INSUR ANCE SUBMISSIONS: I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANY(S) UNDERSTAND I AM RESPONSIBLE FOR MY BILL. I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING ME OBTAIN PAYMENT FROM MY INSURANCE COMPANY(S ): I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR: AND t PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. PATIENT NAME: EPSTEIN: JEFFREY ID NUMBER: DATE 06/C5/2318 PATIENT SIGNATURE FOR OFFICE USE ONLY: MRN#: 0315192 Scrtame cr Form C2-2tt7 It 0 0 0' :0 00 Z IVA AV TE:V $31047/0C,S0 EFTA00313969