ient or Authorized Representative Date Relationship to Patient r%•1/4 Date EFTA00283628 07/25/2014 04:16am hISH Æ47 gent& Facuity Prae:ties RtnRi Doctors {i i ACTC40'itilflGEMETI." OF BP,ar orsorsa OP PRIVACY-PR.4.CrIC.ES • • [NOPP) I abc v ''" signing below, I acicooydtclge*,at I hav