EFTA00313962.pdf

EAST RIVER MEDICAL IMAGING, PC Date: 06/05/2018 PATIENT INFORMATION RECORQ Patient Name: EPSTEIN, JEFFREY Address: 8100 RED HOOK QUARTERS City. SAINT THOMAS State: VI Data of Birth: 01/2W1963 Medical Record Number*: Seam SeCUrity t MOM AOVUnitrSiirte: APT 83 Zip: 00602 E-Mait Primary Phone s. Please validate your referring physician and contact Information by marking the check bons below. K Refernng Physician. MOSKOINITZ BRUCE W MO MD O Referring Physician's Address: 1411 NORTH FLAGLER DRIVE SUITE 7100 WEST PALM RFActi-l_p, 3340' O Referring Physician's Phone 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) =====MMUMM===z=AUMS Mint =Ma - 0 Report & CD ($25.00) 0 Repo-1 & Films ($200.00) Itts_wance Information Insurance Company: WI I7ep 1-I G,Au- HCACc Insureds Nargle: TEF ragy ePS-r-E)nJ Insureds Hat Do you have supplemental/secondary insurance? 0 Yes if yes. Insurance Company: ---=resst Grotm*: a3aceos Insureds DOB: TAM a Or 19 53 Ration to patient c cirt 0 No Insureds ID re Hue your inauroncs Outman, slow your CM VISIT? C vet O No (if yes. Pease fill out insurance information above and supply your new insurance card(s) to the front desk recepacnist) =—________ _ _ -------- — --------- asserm: EXAMS TODAY Date / Time Exam Code Refemno Name Accession 06/05/2018 8:30 AM EDT MRCLAVL MOSKOWITZ, BRUCE W, M.D 7156124 PAYMENT IS DUE AT THE TIME OF SERVICE El Cash 0 Check 0 Mastercaro 0 visa almex 0 Discover HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: 2000/T0002 XV 03:11 STOZ/OC/SO EFTA00313962