LJ 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); * |LAUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR: AND * I 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/S000D) Yv4 AV TZ: STOZ/ot/sO EFTA00313969