eturn CD/Film to my referring physician Patient Signature Front Desk Receptionist Name Front Desk Receptionist Signature 6/Z £LLhh£LZLZ atn5etui ienIpaky iancti 1ss3 Vdd LI- 9Z L SLOZ1£L/LoO EFTA00282927 EAST -RIVER MEDICAL IMAGING. PC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES