ate I authorize paymont of medical benefits to the physician or medical practice for the services rondorod. Name Signature Date EFTA00306878 East Slily Medical Rudloff I'I,I.f Sieved D. Wolff M. 171) r. 77". st., 'St". York %% 10073 (212 )3119-92D0 NIPAA PRIVACY NOTICE • I acknowledge that I hove been