# Profoundd archive — Epstein Files
# Bates number: EFTA00314094
# Title:        Date: TA rj • I 1)a-IDICI
# Dataset:      9
# Pages:        1
# Tags:         epstein, doj, dataset-9
# Source PDF:   https://profoundd.com/epstein-docs/EFTA00314094/download
# Doc viewer:   https://profoundd.com/epstein-docs/EFTA00314094
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=== SUMMARY ===
Date: TA rj • I 1)a-IDICI MITCHELL A KLINE E PATIENT REGISTRATION NAME: J e SOCIAL SECURITY: -53 DATE OF BIRTH1- 2O GENDER 1.\-4 PREFERRED LANGUAGE: I; ICI ‘L1SH Marital Status:eM D W AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ETHNIC GROUP: HISPANIC OR LATINO NOT HISPANIC OR LATINO UNKNOWN ADDRESS: ei CAST ST CITY: NI aVV Nh3114-... HomFis ,41 o tqr CELL# a I a - 53R _ 3-4-39 PHARMACY NAME VI TA t4 EA cm PHONE#_ISTATE: N y ZIP CODE


=== EXTRACTED TEXT ===
Date: TA rj • I 1)a-IDICI 
MITCHELL  A KLINE E 
PATIENT REGISTRATION 
NAME: J e 
SOCIAL SECURITY: -53 DATE OF BIRTH1- 2O  GENDER   1.\-4 
PREFERRED LANGUAGE:  I; ICI ‘L1SH Marital Status:eM D W 
AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR 
AFRICAN AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 
ETHNIC GROUP: 
HISPANIC OR LATINO NOT HISPANIC OR LATINO UNKNOWN 
ADDRESS:  ei CAST ST 
CITY:  NI aVV Nh3114-... 
HomFis ,41 o tqr 
CELL#  a I a - 53R _ 3-4-39 
PHARMACY  NAME VI TA t4 EA cm 
PHONE#_ISTATE:  N y ZIP CODE  local
WORK#  - cat) -q C4 
E-MAIL jetAtaCartionaOyncial.C.Din 
ADDRESS  1,a1S-- `ST Ave • 
FAX* (e 
OCCUPATION/EMPLOYER: ZE2iarar. /4 -71z etcYr CAO. 
REFERRED BY: (PHYSICIAN, PATIENT, FRIEND, OR OTHER) PLEASE CIRCLE AND LIST 
NAME: 
SPOUSE/PARENT: 
FINANCIAL/INSURANCE INFORMATION 
Pr Kline does not narticipate with am health insurance.  I understand that I am responsible for all chargers incurred 
and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory 
purposes only. 
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline. M.D. 
for semices furnished to me by the provider. I authorize any holder of medical information about me to release to CMS 
and its agents any information needed to be determine these benefits payable for relatrrl sen ler% 
CARRIER NAME: LI $ 1-th I-I-GAL-TVCAIZE.7  ID# 
GROUP  (O OS 
Employer Sponsored?  Government Sponsored?  — 
RELATIONSHIP TO INSURED NAME:  S ei% 
KINDLY GIVE 211IR HOURS NOTICE TO CANCEL APPOINTMENTS. 
A FEE OF SI00.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS 
FAILURE TO KEEP SCHEDULED APPOINTMENTS. 
EFTA00314094