K Visa 0 Amex 0 Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: goon/noon WI xv OZ:9 STOZ/OC/SO EFTA00299773 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Oate: 5/30/18 Patient Name: EPSTEIN, JEFFREY Medical Recor