Nuclear Medicine Associates | 1 Gustave Levy Place #1141 New York, NY 10029 (212) 241-5998 MOUNT SINAI scxO or MEDICINE = -—— —__ be Patient Last Name: EP ST E} Social Sec. #; | —_ Patient First Name: J Ee re Qe. | Date of Birth: JANI 20 1953 | Sex: M a FO Address: | 5 S ik | a © AST HIST STReey a Referring MD:| | [ae a ® = * |. Sera a a . Zip_[0O>| Country: LAS A ~ ———$_____ muon Soutuern trust ao, | ™| 340.545. asat | | Primary Insurance: [LUN ITED It+eALT4 CARS a a Name of Policyholder. Policyholder Date of birth: cy! Se a = olicyhoider of birth: JEFFREY EesTent | soe) JAN 201933 | | Relationship to Policyholder = Self Spouse CO Child [1] Other Secondry Insurance: Policy #1 —— ee | | eae Name of Policyholder: ips | Policyholder Date of births! ied edie aun ee oe Relationship to Policyholder: () Self [] Spouse (D Child (J Other Patient Signature: ate: DEC. IS.) =) ef nS) Policy Holder Signature: Pa Date: JYEC 13,2015 i, | 2 abed GLEZERS-ZIZ RUS INOW WYZZ0L LOZ EL 290 EFTA00313791

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an tae Provided by law, te rnp Pear aoe amounts et cova by neat. ry nunc | hve cs mycin cr pee pan the “Payment cary Delance as detained by Mount Sinai immedi upon leaming Uf feck nee ame plans ton fp ncn na Sa Sten ay one an ee ne ot Sat Ste, ede any te otenra sara” MOM Sl Heat So or cad ener cc nw se Sea Pan ed a ay their “professional” services. will be required for ; @N (2) whether the services of other physicians (including but not limited to Eben amy aman ped nce cre jure understand that Il can check with the Services fo obtain the contact information and/or health Participation information Physicians or faciity whose services be sense mm te arson See ceo Say ene Ses eae ae cee SS Seen in | HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE ITEMS, Ec. 13,5017 SIGNATURE OF PATIENT OR AUTH AUTHORIZED REPRESENTATIVE ~DATED RELATIONSHIP TO PATIENT WITNESS TO SIGNATURE Please Turn Page Over € abed QLEZ-E8Z-Z12 RUIS INO W2ZOL LOZ EL 290 EFTA00313792

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= Sl, | 4 Icahn School of Medicine at Mount Sinai Mount Sinai Doctors Faculty Practice Financial Agreement Welcome to Mount Sinai Doctors Faculty Practice (MSDFP), a division of the Icahn School of Medicine at Mount Sinai. We are committed to providing you with the best possible care and are pleased to explain our professional fees to you at any time, Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, our PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL ALSO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE. . REFERRALS ~ If your plan requires a referral from your primary care physician, it ie YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If ow do net have your referral, and cannot obtain one atthe time of your visit, you will be personally tesponsible for that day’s services. ° CO-PAYMENTS ~ By law we MUST collect your carrier’s designated co-pay. This payment is expected at the time of service, Please be prepared to pay the co-pay at each visit. | SELF-PAY PATIENTS ~ Payment is expected at the time of service unless other Hiuancil arrangements have been made prior to your visit. . MEDICARE ~ We will submit claims to Medicare. You will be responsible for the deductible and the 20% co-insurance, which can be billed to a second: y insurance if you have onc. Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to MSDFP for any services furnished to me. I authorize any holder of medical information about me to release it to the CMS (and its agents) to determine the benefits This information will be used for the pu of evaluating and administering agency. We accept CREDIT CARDS (MASTERCARD, VISA, or AMERICAN EXPRESS), CASH, or CHECKS. Our preferred method of payment is by credit or debit card. THANK YOU for taking the time to review our policies. Please feel fee to ask any questions or share any special concems you may have with a member of our s | Patient Name: a “Tone ot aie 4 Jecrey EPsrman| | Jan 30, 3 | t | Clty, State: lie: | REO tec Te af ico 1). 9) Ce Ror Si eee eee ‘3 — es eee =r? gar: ct a niece J Please Turn Page Over y abed QL62-682-Z12Z US WOW WZZ:0l LIOZ €1 2980 EFTA00313793

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Patient Name: JEFEZEY EPsiq) _ Mount | MRM Sinai INFECTIOUS DISEASES SCREENING TOOL Assigned staff should have ALL patisnts answer these questions: 1. Have you traveled outside the U.S. in the past 21 days (3 weeks)? ee at lf yes, where hs Ce Has a close contact (household member) traveled outside the U.S. in the past 21 cays (3 weeks)? if yes, where . Have you had close contact with a person with Ebola? . 0 you have a fever (Temp more than 100.4°F (38°C)) or feel hot? . Do you have a cough or a sore throat? . Are you vomiting or having diarrhea? . Do you have a rash? * During FLU season, think FLU * IDSF MSHS 18Mav15 ¢ eted 9L62-682-212 UIS 2UNOW WYEZOL ZIO2 EL 220 EFTA00313794

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SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER, B-3 €) Unitedtealthcare [eos] >002669 7080107 003062 1! Unitedttealthcare 13082 7080107 0000 0002669 (is 3519 116 EFTA00313795

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