mber: 6/G MRI Clueslionnake 09-2013 £LLPPELZLZ au!tiewi iesipaw iannti Ise3 Nd LL '9Z L SLOZ1£LA3O EFTA00282930 EAST -RIVER MEDICAL IMAGING, PC SIGNATURE ON FILE/INSURANCE AUTHORIZATION CARD " I AUTHORIZE USE OF THIS FORM FOR ALL MY INSURANCE SUBMISSIONS; * I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE CO

EAST RIVER .MEDICAL IMAGING. PC SIGNATURE ON FILE/INSURANCE AUTHORIZATION CARD I AUTHORIZE USE OF THIS FORM FOR ALL MY INSURANCE SUBMISSIONS: I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPAN