East Side Medical Radiology PLLC 170 East 77° Street - Lower Lovel New York, NY 10075 “oo Thal Tosh te208 Home Address EAS New yYoRew a country USA __ Shane bar ttem Ci— a tate XC roma ee ee cnet ataeee (oO RED HOOK QUARTER SuuTES-3, ST.THOMAS 11 OoZod Primary Insurance weme LAN ITED HEALTHCARE, name JEEEREN EPSTEsn| _paney notsor Date of pate JAP SC (9353 <a ~~ 7 Pe 77 ae ee. an: Secondary Insurance Name aaial Polley@_ rrp Phone # of Secondary Insurance Company Policy Holder Name. llc Holder Date of Birth | authorized the release of any medical or other Information necessary to process the claim for services rendered to me. | ats request payment of government benefits or commercial Insurance benofits to myself or the party who accepts the assignment below. name JEFEREY ERSTE) gram wee AN IKONS | authorize paymont of medical benofits to the physician or medical practice for the services rendered. ere Ae Fee} EPSTEIN _ signature — a > Date TALI 20 i EFTA00313930