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 P S it 1 Prat Tref-TRC->) Home Address City 9 eAs--r Niew VcieK— Mau N Country LAs A Name Phone ..0 Cato of Birth &t 0- 57A sir AO. Zip 100-I pa Made Y_ Esmats Emergency Contact Mame iCAR4NA SHUOAIC Oblational* Plelq-klo pimps Name of Employer Employers Address 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 ouri-lo2n) TRiAs-r CAMP. (Sir.) (oleo Ra 14O0K QUAD Su rre bai StilomAs kAti 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