I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ 643etal leoPaN Jame! 1823 Nd LL N L SLOZ1£L/LDO EFTA00282926 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Date: 10/13/15 Patient Name: EPSTEIN, JEFFREY Medical Record Number ft