MITCHELL A KLINE. PATIENT REGISTRATION ee —_ oad NAME: \JEFrREN (EPSTEIA\ ae \-20-63 SOCIAL SECURITY: DATE OF BIRTH GENDER \(___ PREFERRED LANGUAGE: _(E A}GL1SH Marital Status:Q)M D W AUCASIAN> AMERICAN INDIANOR ALASKANATIVE ASIAN BLACK OR AFRICAN AMERICAN _ NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ETHNIC GROUP: HISPANIC OR LATINO NOT HISPANIC OR LATINO UNKNOWN appress: 9 CAST F\st ST. cry: jlew Yee state: _N Y zip cope_| 003} Homes 312-350 - 9X 9S worK#_ 213-750 GR \E CELLA_D1 > - 533-3739 E-MAIL jeevacah oar Com PHARMACY NAME \/ITALIGACTH appress | O25 |®T AVE — FAX#_2> 1 > - Re Sie OCCUPATIONEMPLOYER: SOUTHERN TRUST CO. REFERRED BY: (PHYSICIAN, PATIENT, FRIEND, OR OTHER) PLEASE CIRCLE AND LIST NAME: SPOUSE/PARENT: NAN N Ni v N Dr. Kline docs not participate with any health insurance. 1 understand that | am responsible for all chargers incurred and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory purposes only. I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline, M_D. for services furnished to me by the provider. | authorize any holder of medical information about me to release to CMS and its agents any information needed to be determine these benefits payable for re i Groupe DFQAGOS Employer Sponsored? — Government Sponsored? RELATIONSHIP TO INSURED NAME: _ Save KINDLY GIVE 24HR HOURS NOTICE TO CANCEL APPOINTMENTS. A FEE OF $100.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS FAILURE TO KEEP SCHEDULED APPOINTMENTS. EFTA00314094