LJ EAST RIVER PATIENT INFORMATION RECORD MEDICAL IMAGING, PC Date: 06/05/2018 O Referring Physician: MOSKOWITZ. BRUCEW.MOMD —_ O Referring Physician's Address: 33401 0 Referring Physician's Phone: a Your referring Physician that has ordered this procedure will receive 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: 0 Report Only (No Charge) © Report & CD ($25.00) O Report & Films ($200.00) SSS SSSSSSSTS 8S SSSSSS SSS SS SSSl HSS = =2888S== = ==sesee=====s2ESe8=====sneENK=: ===SsEse=— Insurance Information Insurance Company: Ul 1 TED HEA THCARE Group# AFALOS Insured's Name: EEE; ePstre;,l Insured's DOB: JAN .30,19GS3Z — macnn SF Do you have supplemental/secondary insurance? Ol Yes 0 No If yes, Insurance Company: insured’s ID #: Hao your inaurance chanyou sinvy yuurmstvistz © yes O No Si yse_ DEES Teac werance information sbove and Supply your new insurance card(s) to the front desk receptionist) SSSSS SS SSSR SRS SS EEE SSS ee na nnenneneen.— eens EXAMS TODAY Date / Time Exam Code Refernng Name Agcession 06/05/2018 8:30 AMEDT MRCLAVL MOSKOWITZ, BRUCE W.M.D 7156124 PAYMENT IS OUE AT THE TIME OF SERVICE O casn Ocheck OMastercarc Ovise taAmex 0D piscover ! HEREBY ACKNOWLEDGE THAT | AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: $000/T000D Ivd KV 02: STOZ/0t/S0 EFTA00313962