East Side Medica! Radlology PLLC 170 East 77* Street - Lower Love! New York, NY 40075 Pronc exe As [01% siiceieeined: SORTS pret _JEEEREY Home Address E Eo Eel Apts New yoRe“ ouee YY tp_LOOD-| coy (ASA tome Prone AION aIS anna patoctsith O1-2 0-52 sox scx tts X remate ceca PERN BOE eg = aamaREG URE Te Name of Employer Ou THERA 1S Employers address (0100 RED HOOK QUARTES ae 3 STTHOMAS “VI Oogor Primary tneurance Mame LAN ITED HEALTHCARE Polley Holder Name Ji RO 7 Holder Date of Birth JAW SO (953 Policy Holder Name 0 sé licy Holder Dato of Birth | authorized the release cf any medical or cther Infermation necessary to process the claim for services rendored to me. | also request payment of government bonefits or commercial insurance benefits to myself or the party who accepts the assignment below. ene EREN CPST E/A! signature vere JAN [P2016 | authorize paymont of medical bonofits to the physician or medical practice for the services rendered. EFTA00313922