f I DATE Of BIRTH November 07 [991 PAINIENT INFORMATION: tpplicarloalt ethion Fee: $410.00 3 0000384; litotnartr. Fri-. $0.00 Total %nttount Reechoed: $410.00 l i ll il l i l l i rli f i lli lli fi rl ia l ibi l i ll+I I I II I ii i ill i l ll i lll'll Total Balance Doe: $000 N t ' I F. AND NI