WPC *N쌣OɊ#p3uTPIHq.z-8s2_axNs0@\ 릳f]v8&ڼΧQC !c\ﳘ_!hX;C xK ɘJZl<;3u6"iI `:ïQaR!ͮ!{u ]n6[7 {u5Omў3j.JTԳ! Uo7"ީZP Zz˜v̀hs9'**^GzpI0mKjVuWul!Myh8J癅nfe?d;E[،~lЙ79`vtJJLHvG:۹$̌?c#jUN+ %y 0: R V 0c ^ < wH 4L ` o mq 0 U* U< 72 N 0" 07 0h D+hhh 1e 1u 1ummmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm B B\\NJFS1\HP 4050 Leann0(9 Z6Times New Roman RegularX($USUS.,LAWMakeDetail(;3$2#  0  .3  0  v(/s ("/Sx)Xǫ3|xU2S+P 0_level1  , ;1` hp x (#;23  ..  8.` hp x (#8  %2A`ArialC`$Century Gothic9i)6: *4Heading 2&&&       XXX 6y {4Heading 3?%2A`Arial?       XXXQC`$Century GothicQ 6 4Body Text    'dxd(35;AGMSY_11.1.1.1.1.1.1.1.(35=EMU]em2(a)(a)(a)(a)(a)(a)(a)(a)3#37=CIQYag1.a.i.(1)(a)(i)1)a) d d !USUS.,  _ XXXX  AUTHORIZATIONFORM   INDIVIDUALSNAME:L  _PlName_M#XXXXx#XXXX0  DATEOFBIRTH:L  _PLDOB_M#XXXX^#XXXXt(#(# INDIVIDUALSADDRESS: h L  PlAddr1MaL  PlAddr2M L     `     h L  _PlCity_M,L  _PlState_M0#XXXX#XXXX 8    Iherebyauthorizeuseordisclosureofprotectedhealthinformationaboutmeasdescribed  ` below.  L  1.0  Thefollowingspecificperson/classofperson/facilityisauthorizedtouseordisclose $  informationaboutme: (#(#    ` L  _PlDr_M$      ` L  _PlDrFirm_M      ` L  PlDrAddr1ML  PlDrAddr2M      ` L  _PlDrCity_Mi,L  _PlDrState_MހL  _PlDrZip_M#XXXX#XXXX p 2.0  Thefollowingperson(orclassofpersons)mayreceivedisclosureofprotectedhealth H informationaboutme:His/her/itsnameandaddress:4(#(#    `     h   _Mintzer_,_Sarowitz_,_Zeris_,_Ledva_Ԁ&Meyers  \   2070SpringdaleRoad,Suite400 H   CherryHill,NewJersey08003 4 3.0  Thespecificinformationthatshouldbedisclosedis(pleasegivedatesofserviceif   possible):(#(#  0  Anyandallinformationyoumayhaveregardingmyconditionwhileunderyour  observationincludingthehistoryobtained,record,xrays,reportsorcopiesthereof l relatingtomyexamination,consultation,confinementortreatmentandphysical X  findings,diagnosisandprognosis,andtopermitthemtoinspectandmakecopiesor D! abstractsthereof.Youarealsoauthorizedtosendanypsychiatric,drugand/or 0"  alcoholicinformationifapplicable. #l!(#(# 4.0  UNLESSYOUSIGNHERE ,NOINFORMATIONABOUTALCOHOL/SUBSTANCE $D # ABUSE,HIV/AIDS,ORMENTALHEALTHWILLBEDISCLOSED:%4!$(#(#    `    򀀀YES ,DISCLOSETHISINFORMATION򀀀 ' #&    `  NO,DONOT DISCLOSETHISINFORMATION򀀀 (#' 5.0  Iunderstandthattheinformationusedordisclosedmaybesubjecttoredisclosurebythe t+&* personorclassofpersonsorfacilityreceivingit,andwouldthennolongerbeprotected `,'+ byfederalprivacyregulations.L-(,(#(# Ї6.0  Imayrevokethisauthorizationbynotifyinginwritingofmydesiretorevokeit.  However,Iunderstandthatanyactionalreadytakeninrelianceonthisauthorization  cannotbereversed,andmyrevocationwillnotaffectthoseactions.Iunderstandthatthe  medicalprovidertowhomthisauthorizationisfurnishedmaynotconditionitstreatment t ofmeonwhetherornotIsigntheauthorization.`(#(# 7.0  Thisauthorizationexpires: upontheconclusionofthepersonalinjuryclaimformy 8  accidentof L  DOA Mt, beinghandledbyL  _AttyName_M.( x(#(#  #XXXXO#XXXX  THISFORMMUSTBEFULLYCOMPLETEDBEFORESIGNINGnotethat  @  signatureisrequiredintwoplaces. ,   򀀀󀀀򀀀   SignatureofIndividual   h      p SocialSecurityNo.   (Thepersonaboutwhomtheinforelates) x    `     h      p 򀀀 d    `     h      p Date P #XXXX3# lXX#XX l#XXXXOr,ifapplicable#XXXX#XXXX P 򀀀󀀀򀀀󀀀򀀀  SignatureofGuardianor0  0h(#(#0h(#h(#Date0(#(#0p(#(#DescriptionofAuthoritytoActp(#p(# PersonalRep.ofPatientsEstate0 h 0h(#h(#0(#(#0p(#(#fortheIndividualp(#p(# _#XXXXV# _