Medical Record Number #: 0315192 Please validate your referring physician and contact information by marking the check boxes below, O Referring Physician: MOSKOWITZ, BRUCEW. MO.MD O Referring Physician's Address: 1411 NORTH FLAGLER DRIVE SUITE 7100 WEST PALM BEACH, FL 33401 O) Referring Physician's Phone: Yt TTT] Your referring Physician that has ordered this procedure will recoive reports, films and/or CD (their preference), Please indicate by marking in the check box if you would like any additional processing to yourself or other physicians Additional Physicians Name: Address: Additional Reports To: Address: O Report Only (No Charge) OD Report & CD ($25.00) O Report & Films ($200.00) Insurance Company: Group #: Insured's Name: Insured's DOB: Insured's ID#: Relation to patient: Do you have supplemental/secondary insurance? Ol ves 0 No If yes, Insurance Company: Insured’s ID #: Hoo your inaurance Llianyeu sitive yuur last Visit? O ves O No (if yes, please fill out insurance information above and supply your new insurance card(s) to the front desk receptionist.) ==SS2' =S2e2 —_ a= =s a ye 0 es EXAMS TODAY Date / Time Exam Code Referring Name Accession 06/05/2018 8:30 AMEDT MRCLAVL MOSKOWITZ, BRUCE W,M.D 7156124 PAYMENT IS OUE AT THE TIME OF SERVICE O cash OcCheck OMastercacd Ovise Oamex O Discover | HEREBY ACKNOWLEDGE THAT | AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: eee £000/TO00R X¥d KY 02:8 STOZ/0¢/¢s0 EFTA00299773

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MEDICAL IMAGING, PC Date: 5/30/18 Patient Name: EPSTEIN, JEFFREY Medical Record Number #: 0315192 Do you have any relevant outside studies (films/CD) with you? O yes O No If Yes, please check the box as to how you would like your outside images returned QO) Upload CD to our system and take back with you O) Return CD/Film to my home address on file O Return CD/Film to my referring physician Patient Signature es Front Desk Receptionist Name Front Desk Receptionist Signature £000/2000H X¥d KY 02:8 8TOz/0¢/¢S0 EFTA00299774

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ERIVER ACKNOWLEDGEMENT OF RECEIPT MEDICAL IMAGING, PC OF NOTICE OF PRIVACY PRACTICES |, EPSTEIN, JEFFREY | have received the Notice of Privacy Practices from East River Medical Imaging, PC, PATIENT SIGNATURE: 3/30/18 i In lieu of patient signature, |, , a staff member of East River Medical Imaging, PC state that the patient named above has been given our current Notice of Privacy Practices, STAFF SIGNATURE: _ DATE: PATICNT NAMC: FPSTFIN, .IFFFREV 0315192 ¢000/¢000R X¥d KY 02:8 STOZ/0¢/¢S0 EFTA00299775

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EAST =4= RIVER. MEDICAL IMAGING. PC MAGNETIC RESONANCE IMAGING (MRI) Patient Name: EPSTEIN, JEFFREY MRN #: 0315192 Exam Code: MRCLAVL Age: 65 Years Sex: M Height: Feet Inches Weight: Ibs Exam Date: 06/05/2018 Referring Physician: MOSKOWITZ, BRUCE W, M.D. M.D. Acc# 7156124 IMPORTANT: Please notify the receptionist if you answer "YES" to any of the questions below, The receptionist will inform the technologist/radiologist of your response. YES NO PLEASE CHECK: oO Have you had metal removed from your eyes? Have vou been shot with bullets, BB's or shrapnel? Are you pregnant? Are you nursing? Are you on hemodialysis or peritoneal dialysis? Do you require oxygen or an inhaler? Do you have renal disease? If yes please describe Are you wearing any metallic items? Any surgery on the area to be imaged? If yes, when? Any surgery on your eyes, ears brain or heart? Have you had a Colonoscopy and/or Endoscopy within the last 6 weeks? If yes, date of exam DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? Brain/Aneurysm Clips Pacemaker, Pacer Wires or Defibrillator if yes, make\ year Any Metallic fragment or foreign body Ear Implants or Hearing Aids Electrical Stimulators Implant/Prosthesis Infusion Pumps Coils, Catheters, Filters or Wires in blood: Artifical Limbs or Joint Replacement Tattooed Eveliner Artificial Heart Valves Stents If yes, please provide date of implant: Maanetic Dental Implants one Patches ooo0000co00 OoOococo0000D00 Y' m w Tissue expander for future implants Bone Stimulators. Insulin Pumps. or Mechanical Valves Programmable Shunts WARNING: Before entering the MR room, you must remove all metallic objects including HEARING AIDS, DENTURES, CREDIT/BANK CARDS, watch, keys, cell phone, beeper, hair pins, barrettes, body piercing jewelry, money clips, magnetic strip cards, pens, pocket knife, and nail clipper. Please consult the technologist if you have any questions or concerns BEFORE you enter the MR room, DNoOooOooOooOoOoOoboOoOoo0co oo00D0D00000000co000 sg Signature: Print Name: Date: 06/05/2018 — Orel _—_—ETe Technologist's Use Only Patient Complaint/Diagnosis: Any previous imaging studies in this area? yes O no If yes, where?, Technologist: Wet Reading CO YES [C2 NO Dr's Phone Number: _ MRI Questionnaire 08-2013 ¢000/F000R Xvd WY T2:8 SToz/Oot/so EFTA00299776

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a EAST == RIVER MEDICAL IMAGING, PC SIGNATURE ON FILE/INSURANCE AUTHORIZATION CARD * | AUTHORIZE USE OF THIS FORM FOR ALL MY INSURANCE SUBMISSIONS; * [AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANY(S): * |'UNDERSTAND | AM RESPONSIBLE FOR MY BILL. * | AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING ME OBTAIN PAYMENT FROM MY INSURANCE COMPANY(S); * [AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR: AND * | PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. PATIENT NAME: EPSTEIN, JEFFREY ID NUMBER; DATE: 06/05/2018 PATIENT SIGNATURE: FOR OFFICE USE ONLY: MRN#: 0315192 Signature on File Form 02-2007 ¢000/s000R X¥d KY Te: sToz/oe/so EFTA00299777