iary or his/her legal representative understands that Medi-Gap plans do and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. : Beneficiary or his/her legal representative acknowledges that the beneficiary is not ly in an emergency or urgent health care situation, | iary or his/her legal representative acknowledges that a copy of this has been made available to him. aa ye | Lyi Date: SEPT dl, 908 ii oo... Date? _____. By: Benefi¢i i And: } | Darius Paduch, M.D. EFTA00314072