WPC >U+.@K4ylk ШȣV`ZIB÷v pnAqecpACkJU#|2J,Òɕu0b'nkKԐxMݖ1htO+j3qYiSudѯ4A`O.) p< 7MXXL]pkdXH;3(m|9CXFckvnM u @d+9"6h~CҎ!c-%el ͙|PW{`+spukh d P 8oo\ۿ"-\+[ 9޴1`NՍ><$e GPΘD1V8fGTwD,YM Tc[aC(5mT& J,$~L lY.V5 $U&>6 0  0< 0 UB 0 U, D+ C 03 U0 < 0 0( AMoH@o@o@em 0}#3UN %BMH(LNt^ vw4 m\  `&Times New Roman' PATIENT REGISTRATION FORM Shepard0Shepard .   6g `4Heading 1XXX 8.,,X <DL!T$&8   A7,,4 <DL!T$&A <:Default Para. ,Title999W*jp`*Bookman Old StyleW   &,,!T$&&  J@,4 <DL!T$&JS\  `&Times New RomanS *jp`*Bookman Old Style< :Document MapA $TahomaAC 4$X ddCA $TahomaA  7 (X7S\  `&Times New RomanS  $Tahoma'dxddd8:g 6Block Text      ?!     D:,4 <DL!T$&D*jp`Garamond Level 1 Level 2 Level 3 Level 4 Level 5(29>$ 5!,,..      %XX%%  ($  A<< cWPCx 1x 1x 1 Wx 1}.3 g`w<7@ ?  +++++++@?  '      9 XXp IherebyauthorizeMountainsideInternalMedicinereleasetoanycompanywhichhasissuedtomemedical +($0 orhospitalizationinsurance,allinformationregardingtreatmentbysaiddoctorandIfurtherassigntosaid (f%1 doctorallmedicalandsurgicalbenefitspayabletohim/herundersaidpolicy.Ifurtheragreetopaysaid )%&2 doctorforanychargesforprofessionalservicesnotcoveredbysuchpolicy.MountainsideInternal h*&3 MedicinemayaccessanypartofmyrecordsfromSt.Peter'sHospital(includingtreatmentforalcoholor '+'4 drugabuse)forcontinuityofcarepurposesand/orfortheadjudicationofallclaimsrelatingtopaymentof +b(5 servicesconnectedwiththehospitalizationasprovidedbytheHealthCareInformationAct.Recordsmay ,!)6 beaccessedinhardcopyorbycomputer.  ?!'  XpX9    6,,L!T$&,,?n&>6 Signature  Date #.*8 W7,,4 <DL!T$&,,LX&WVFBx \ynp{o@XE, /ynyn /nVFBx \rpv@XEe/rre/9 XXp  /+9