Epstein File EFTA00287148: Holder and Minor (DS9)

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⚡IMPACT LEVEL 3 — NOTEWORTHY

Epstein File EFTA00287148: Holder and Minor (DS9)

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This document is a medical test authorization and billing form that includes fields for patient information, parent/guardian information for minors, and insurance policy holder details. The form references a patient in NYC, NY, includes an ID number (854905597), group number (272605), and requests authorization for release of medical information. The document appears to be a standard healthcare administrative form.

👤 Named in This Document

Eric Holder

🔑 Evidence Keywords

minor

📋 Key Excerpts3

PersonKeyword

Excerpt 1

PURPOSE OF TEST URINE VENOUS INITIAL AYN REPEAT FINGERSTICK FOLLOW-UP 1500.11 RESPONSIBLE PARTY'S EMPLOYER (IF ADULT) 31143092-0 PARENT/GUARDIAN NAME (IF **MINOR**

Excerpt 2

PARTY PATIENT City NYC NY State ZIP D 1065 PRIMARY BILLING PARTY SECONDARY BILLING PARTY Name of Policy **Holder** (if different from patient) Insurance Carrier

Excerpt 3

Address of Policy **Holder** APT # ID. 854905597 ID City State ZIP Group #: 272605 Group # hereby authorize the release of medical information related to the