East Side Medical Radiology PLLC 170 East 77" Street - Lower Leval Mow York, NY 10075 Phone 212-369-9200 Date Patient Last Name Find Homo Address Apt 0 City State Zip Country Home Phone Work Phono Coil Phone Date of Birth SS0 Sex Male Female Emergency Contact Name Relationship Phone Name of Employer Employers Address Primary Insurance Name Policy Holder Name Policy Holder Date of Birth Policy tl Group Phone Number of Insurance Company Secondary Insurance Name Policy tl Group 0 Phone 0 of Secondary Insurance Company Policy Holder Name __ Policy Holder Date of Birth I authorized the release of any medical or other information necessary to process the claim for services rendered to mo. I also request payment of government benefits or commercial insurance hemline to myself or the party who accepts the assignment below. Name Signature. - - -- Date I authorize paymont of medical benefits to the physician or medical practice for the services rondorod. Name Signature Date EFTA00306878