S. ( \--vBeneficiary or his/her legal representative understands that Medi-Gap plans do nk, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. l\--Beneficiary or his/her legal representative acknowledges that the beneficiary is not cukently in an emergency or urgent health care situation. Beneficiary or his/her legal representative acknowledges that a copy of this confr.acti has been made available to him. Executed on: Date: gae? By: And: Darius Paduch, M.D. 11111111111111 2935318 EPSTEIN,JEFFREY 01/20/1953 Initial:___ Date: EFTA00314072