MEARISTVER
MEDICAL IMAGING. PC
ACKNOWLEDGEMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
I. EPSTEIN, JEFFREY , have received the Notice of Privacy Practices from
East River Medical Imaging, PC.
PATIENT SIGNATURE
5/30/18
in lieu of patient signature, I,
, a staff member of East River Medical
Imaging, PC state that the patient named above has been
given our current Notice of Privacy Practices.
STAFF SIGNATURE
DATE
PATICNT NAMC. FPSTFIN, .irgFRPV
0315192
S000/C00045 IVA KV oz:s OTOZ/OC/S0
EFTA00313966