ist: Wet Reading K YES D NO Dr's Phone Number: MR1 Questionnaire 09-2013 YVI fit TZ:8 9TOZ/OC/S0 EFTA00299776 REAST IV MEDICAL imAGINGE. PAC SIGNATURE ON FILE/INSURANCE AUTHORIZATION CARD • I AUTHORIZE USE OF THIS FORM FOR ALL MY INSURANCE SUBMISSIONS: * I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE CO