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5.0261 -2.4778 2.8484 -2.1751 -.001 c 0 0 l f Q q 1 0 0 1 303.348 742.512 cm 0 0 m -.4386 3.9014 .1616 9.6497 y -2.1931 9.6497 l -1.5929 3.9014 -2.0315 0 v -.808 -.4155 0 0 v f Q EMC /Artifact <>BDC Q q 1 i 0 792 612 -792 re 306 396.015 m W n 0 792.015 612 -792 re W n 0 0 0 1 K 0 J 0 j .5 w 10 M [] 0 d /GS2 gs 111.25 755.75 101.5 -17.5 re 213.49 583.812 m S EMC /P <>BDC BT /TT2 1 Tf 9 0 0 9 117.1985 744.3896 Tm 0 Tc .0278 Tw [(\(For Of)17.6(ficial Use Only\))]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 568.8125 Tm [(INFORMACIN DEL)17.6( P)73.7(ACIENTE:)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 160.3696 568.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 36 555.8124 Tm .0278 Tw (Nombre del paciente:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 114.9611 555.8124 Tm 0 Tw (____________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 280.1383 555.8124 Tm .0278 Tw [( )54.7(Apellido de soltero: _______________ Fecha de nacimiento: ___)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 527.3686 555.8124 Tm 0 Tw (_)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 533.3332 555.8124 Tm (/___)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 549.3901 555.8124 Tm (_)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 555.3549 555.8124 Tm (/____)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 555.8124 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 547.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT 7 0 0 7 119.2045 547.8125 Tm 0 Tc .0278 Tw (Apellido, nombre, inicial del segundo nombre)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 259.8727 547.8125 Tm .0278 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 264.9154 547.8125 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 534.8124 Tm .0278 Tw (N. de telfono:_____________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 263.1844 534.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 521.8124 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 74.7917 521.8124 Tm (_________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 299.6163 521.8124 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 580.5842 521.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 506.8125 Tm .0278 Tw [(INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA)36.6( DE: \(Marque la casilla o complete la informacin\) )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 381.098 506.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 493.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 493.8125 Tm .0278 Tw [( Rush)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 65.115 493.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 67.1775 493.8125 Tm .0278 Tw (University Medical)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 134.3414 493.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 136.4039 493.8125 Tm .0278 Tw (Center )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 166.2087 493.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 173.543 493.8125 Tm .0278 Tw [( Rush)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 195.3237 493.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 197.3862 493.8125 Tm (Oak)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 212.5166 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 214.5792 493.8125 Tm (Park)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 231.5424 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 233.6049 493.8125 Tm .0278 Tw (Hospital )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 268.4532 493.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 275.7875 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 277.85 493.8125 Tm (Copley)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 303.5306 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 305.5931 493.8125 Tm .0278 Tw (Memorial Hospital )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 376.8852 493.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 384.2195 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 386.282 493.8125 Tm -.0269 Tw (Rush Aurora)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 432.3737 493.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 434.4363 493.8125 Tm (Surgery)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 463.3234 493.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 464.927 493.8125 Tm .0278 Tw (Center )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 494.7318 493.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 502.066 493.8125 Tm .0278 Tw [( Rush Medical Group)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 580.2465 493.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 480.8124 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 480.8124 Tm .0278 Tw [( Nombre de la persona u organizacin: )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 192.3604 480.8124 Tm 0 Tw (________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 412.5967 480.8124 Tm .0278 Tw [( N. de telfono:______________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 480.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 467.8125 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 77.0242 467.8125 Tm (_______________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 182.5541 467.8125 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ N. de F)54.7(AX:_______________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 467.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 452.8125 Tm .0278 Tw [(DIVULGAR LA)36.6( INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA)36.6( )36.6(A: \(Se puede facturar al solicitante, a menos que sea un consultorio mdico para la )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 575.0945 452.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 442.8125 Tm .0278 Tw (continuacin de la atencin\))Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 148.0748 442.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 429.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 429.8125 Tm .0278 Tw [( Marque la casilla si es igual a la informacin del paciente anterior )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 289.3589 429.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 416.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 416.8125 Tm .0278 Tw [( Nombre de la persona u organizacin: )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 192.3604 416.8125 Tm 0 Tw (________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 412.5967 416.8125 Tm .0278 Tw [( N. de telfono:______________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 416.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 403.8125 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 77.0242 403.8125 Tm (_______________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 182.5541 403.8125 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ N. de F)54.7(AX:_______________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 403.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 388.8125 Tm (FINALIDAD:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 83.1998 388.8125 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 375.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 375.8125 Tm .0278 Tw [( Continuacin de la atencin )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 155.9311 375.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 163.2654 375.8125 Tm .0278 Tw [( Para registros personales )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 267.8141 375.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 275.1484 375.8125 Tm .0278 Tw [( Seguro )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 311.8368 375.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 319.1711 375.8125 Tm .0278 Tw [( Legal )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 349.4424 375.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 356.7766 375.8125 Tm .0278 Tw [( Otro \(especifique\): )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 433.764 375.8125 Tm 0 Tw (_______________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 375.8125 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 360.8125 Tm .0278 Tw [(FORMA)73.7(T)17.6(O)0( PREFERIDO:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 130.3469 360.8125 Tm .0278 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 135.3896 360.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 142.7239 360.8125 Tm .0278 Tw [( Papel)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 166.3455 360.8125 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 170.4705 360.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 175.5132 360.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 182.8475 360.8125 Tm .0278 Tw [( CD)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 197.2846 360.8125 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 201.4096 360.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 206.4523 360.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 213.7865 360.8125 Tm .0278 Tw [( Fax al nmero:_________________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 386.4956 360.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 346.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 346.8125 Tm .0278 Tw [( Direccin de correo electrnico segura:)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 190.5864 346.8125 Tm 0 Tw (____________________________________________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 346.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 333.8124 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 61.2135 333.8124 Tm 0 Tc (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 65.3385 333.8124 Tm .0278 Tw [(Si elige Papel o CD: )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 150.1719 333.8124 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 157.5061 333.8124 Tm .0278 Tw [( Llame al paciente para que lo recoja )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 309.5339 333.8124 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 316.8682 333.8124 Tm .0278 Tw [( Enve por correo a la direccin del paciente anterior)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 510.1637 333.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 314.8125 Tm .0278 Tw [(FECHAS: Del____ /____ /____ al ____ /____ /____)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 241.9272 314.8125 Tm [(. \(V)54.7(er prrafo V)17.6(igencia en la pgina 2\))]TJ ET EMC /Artifact <>BDC 33.25 288.25 545.5 -83.5 re 390.368 314.812 m S EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 278.625 Tm [(TIPO DE VISIT)73.7(A:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 102.4345 278.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 265.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 265.6249 Tm .0278 Tw (Paciente hospitalizado )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 132.892 265.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 252.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 252.6249 Tm .0278 Tw (Sala de emergencias )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 127.9236 252.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 239.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 239.625 Tm (Otro )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 239.625 Tm (__________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 228.0038 239.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 226.625 Tm (__________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 576 226.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 213.6249 Tm (__________________________________)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 251 274.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 260 274.625 Tm (Ambulatori)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 300.6282 274.625 Tm (o)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 306.3009 274.625 Tm (/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 309.1352 274.625 Tm (Clnica: )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 341.4813 274.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 274.625 Tm (Dr)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 366.5165 274.625 Tm .1112 Tc (./)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 373.1305 274.625 Tm 0 Tc (Dpto. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 400.0901 274.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 274.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 261.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 261.6249 Tm (Ubicacin )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 400.0901 261.6249 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 261.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 248.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 248.625 Tm (Dr)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 366.5165 248.625 Tm .1112 Tc (./)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 373.1305 248.625 Tm 0 Tc (Dpto. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 400.0901 248.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 248.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 235.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 235.625 Tm (Ubicacin )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 400.0901 235.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 235.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 222.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 222.6249 Tm (Dr)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 366.5165 222.6249 Tm .1112 Tc (./)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 373.1305 222.6249 Tm 0 Tc (Dpto. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 400.0901 222.6249 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 222.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 209.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 209.625 Tm (Ubicacin )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 399.8538 209.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 209.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 577.3616 209.625 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 7.5 0 0 7.5 36 181.3749 Tm .0278 Tw [(P)73.7(ASO 1 DE 3)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 82.3393 181.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 168.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 168.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 168.375 Tm .0278 Tw (Solo resumen)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 91.4828 168.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 159.375 Tm .0278 Tw (\(Resumen de alta, historial )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 137.1263 159.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 150.375 Tm .0278 Tw (y examen fsico, notas de)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 130.8787 150.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 141.375 Tm (consultori)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 77.0984 141.375 Tm .0556 Tc (o/)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 84.1874 141.375 Tm 0 Tc .0278 Tw (progreso, informes)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 146.9227 141.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 132.375 Tm .0278 Tw (operativos, notas de urgencias,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 149.8561 132.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 123.375 Tm .0278 Tw (informes de patologa,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 119.6294 123.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 114.375 Tm .0278 Tw (consultas, electrocardio )Tj 10.5331 0 TD 0 Tw (gramas,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 151.0909 114.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 105.375 Tm .0278 Tw (informes de radiologa, informes)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 152.7602 105.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 96.375 Tm .0278 Tw (de laboratorio\))Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 93.5702 96.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 82.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 82.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 82.3749 Tm .0278 Tw (Historial mdico completo)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 131.2822 82.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 68.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 68.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 68.3749 Tm .0278 Tw (Otro; O adems de Resumen,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 145.8787 68.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 59.3749 Tm .0278 Tw (seleccione en el Paso 2)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 193.625 Tm [(INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 36 292.625 Tm [(UBICACIN DE LOS REGISTROS QUE SE SOLICIT)73.7(AN:)]TJ ET EMC /Artifact <>BDC q 1 0 0 1 159 190 cm 0 0 m 0 -144 l S Q EMC /Artifact <>BDC q 1 0 0 1 387 190 cm 0 0 m 0 -144 l S Q EMC /P <>BDC BT 7.5 0 0 7.5 162 181.3749 Tm [(P)73.7(ASO 2 DE 3 \(SI ES NECESARIO\))]TJ ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 281.8917 181.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 168.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 168.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 168.375 Tm .0278 Tw (Resultados de pruebas)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 248.5518 168.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 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0 10 570.9257 748.7273 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 10 0 0 10 369.7505 736.7273 Tm .0278 Tw [(DE INFORMACIN MDICA)36.6( DEL)17.6( P)73.7(ACIENTE)]TJ ET EMC Q endstream endobj 167 0 obj <>/XObject<>/ExtGState<>>> endobj 277 0 obj <> endobj 283 0 obj <>stream /Artifact <>BDC q 1 i 0 792 612 -792 re 306 396.015 m W n 0 792.015 612 -792 re W n 0 0 0 1 K 0 J 0 j 1.5 w 10 M [] 0 d /GS2 gs q 1 0 0 1 288 756 cm 0 0 m 0 -120 l S Q EMC /Artifact <>BDC q 1 0 0 1 36 636 cm 0 0 m 540 0 l S Q EMC /P <>BDC BT /TT4 1 Tf 8.9725 0 0 9.25 36.0189 623.0625 Tm 0 0 0 1 k 0 Tc .0278 Tw [(LEA)36.6( CUIDADOSAMENTE LAS SIGUIENTES DECLARACIONES:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.9725 0 0 9.25 303.8822 623.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 608.0625 Tm .1843 Tw (Esta autorizacin es voluntaria. Rush no condicionar su tratamiento en base a dar esta autorizacin. Sin embargo, Rush puede)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0265 608.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 598.0624 Tm .0278 Tw (condicionar la provisin del tratamiento relacionado con una investigacin en base al otorgamiento de una autorizacin.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 515.1041 598.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 583.0625 Tm -.0232 Tw (Entiendo que puedo cambiar de opinin y revocar esta autorizacin por escrito en cualquier momento notificando a la oficina de )Tj 56.4043 0 TD 0 Tw (contacto)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0267 583.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 573.0624 Tm .0925 Tw (antes listada. Entiendo que la revocacin de esta autorizacin no afectar la accin que Rush tom basndose en esta autorizaci)Tj 59.0722 0 TD 0 Tw (n)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0267 573.0624 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 563.0625 Tm .0278 Tw (antes de que Rush recibiera mi notificacin escrita de revocacin.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 299.5999 563.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 548.0625 Tm -.0408 Tw (Autorizo el uso y/o divulgacin de mi informacin de salud protegida \(Protected Health Information, PHI\) como se describe anter)Tj 56.016 0 TD 0 Tw (iormente.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0269 548.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 538.0625 Tm .0734 Tw (Entiendo que esta autorizacin es voluntaria y se realiza para confirmar mi decisin de manera que Rush pueda usar y/o divulgar)Tj 58.7781 0 TD [( mi)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0267 538.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 528.0624 Tm -.0159 Tw (PHI para un propsito especfico. Entiendo que si las personas u organizaciones que yo autorice arriba para recibir y/o usar la)Tj 55.5473 0 TD [( PHI antes)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0264 528.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 518.0624 Tm .0118 Tw (descrita no estn sujetas a leyes de privacidad de la informacin de salud federales, ellos pueden adems divulgar la PHI y st)Tj 56.558 0 TD (a puede)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.027 518.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 508.0625 Tm -.0142 Tw (no estar ya protegida por leyes de privacidad de informacin de salud federales. Entiendo que tengo el derecho de inspeccionar )Tj 56.6973 0 TD (y copiar)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0271 508.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 498.0624 Tm .007 Tw (la informacin que va a ser divulgada de conformidad con esta autorizacin y que puedo tener una copia de la informacin contac)Tj 57.6821 0 TD 0 Tw (tando)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0269 498.0624 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 488.0625 Tm .0278 Tw (a la oficina indicada arriba.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 143.7528 488.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 473.0625 Tm -.012 Tw (He tenido toda oportunidad de leer y considerar los contenidos de esta autorizacin, y confirmo que los contenidos son consiste)Tj 56.4164 0 TD (ntes con)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0267 473.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 463.0625 Tm -.0006 Tw (mi instruccin a Rush. Entiendo que, mediante la firma de este formulario, confirmo mi autorizacin para que Rush pueda usar o )Tj 57.1279 0 TD 0 Tw (revelar)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0266 463.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 453.0624 Tm .0278 Tw (a las personas y/u organizaciones nombradas en este formulario la PHI descrita en el presente.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 419.5525 453.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.9725 0 0 9.25 36.0189 438.0625 Tm .0001 Tw (VIGENCIA: Esta solicitud de autorizacin no aplica a cualquier fecha de tratamiento ms all de la fecha de firma. Usted puede)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0262 438.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 428.0625 Tm .0373 Tw (elegir estipular un evento \(relacionado con usted o el propsito del us)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 339.3339 428.0625 Tm 0 Tw (o)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 345.3136 428.0625 Tm .0373 Tw (/divulgacin\) sobre el cual su autorizacin expirar, a)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0264 428.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 418.0625 Tm .1373 Tw (menos que los expedientes de salud mental sean requeridos. De lo contrario, esta autorizacin expirar noventa \(90\) das)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0269 418.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 408.0625 Tm .0278 Tw (calendarios despus de la fecha de firma.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 215.0414 408.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.7875 0 0 9.25 38.4141 393.0625 Tm (______________________________________________________________________________________________________________)Tj ET EMC /P <>BDC BT 8.7875 0 0 9.25 576.0049 393.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.7875 0 0 9.25 38.4141 377.0625 Tm (______________________________________________________________________________________________________________)Tj ET EMC /P <>BDC BT 8.7875 0 0 9.25 576.0049 377.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 361.0625 Tm .0278 Tw [(FIRMA)36.6( DEL)17.6( P)73.7(ACIENT)]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 128.856 361.0625 Tm 0 Tw (E)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 136.0544 361.0625 Tm (/)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 139.1388 361.0625 Tm .0278 Tw [(REPRESENT)73.7(ANTE PERSONAL:)]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 277.4773 361.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 9.25 0 0 9.25 36 351.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 341.0624 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 331.0625 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 348.0208 331.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 384 331.0625 Tm (Fecha:)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 415.6677 331.0625 Tm (______________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 570 331.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 321.0624 Tm .0278 Tw (Firma del paciente o representante personal )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 221.6205 321.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 311.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 301.0625 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 291.0624 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 348.0208 291.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 384 291.0624 Tm .0278 Tw (Nmero de telfono:)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 472.2563 291.0624 Tm 0 Tw (___________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 570 291.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 281.0625 Tm .0278 Tw (Si est firmado por otra persona que no es el paciente: )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 266.6172 281.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 271.0625 Tm .0278 Tw [(Nombre del representante en LETRA)54.7( DE IMPRENT)73.7(A)]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 254.8447 271.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 261.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 251.0625 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 241.0625 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 348 241.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 231.0624 Tm .0278 Tw (Si est firmado por otra persona que no es el paciente: )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 266.6172 231.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 221.0625 Tm .0278 Tw (Relacin de estado con el paciente )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 184.1012 221.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 211.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 201.0624 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 9.25 0 0 9.25 36 191.0625 Tm (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 9.25 0 0 9.25 40.6019 191.0625 Tm -.0028 Tc .0052 Tw (\(Se requiere la firma de un testigo que haya verificado la identidad del pacient)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 358.4923 191.0625 Tm .0528 Tc 0 Tw (e/)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 367.184 191.0625 Tm -.0028 Tc .0052 Tw (representante personal para pruebas genticas, de)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 575.9745 191.0625 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 181.0625 Tm -.0028 Tc .0886 Tw [(VIH y registros de consumo de drogas y alcohol. )54.7(Adems, se necesita la firma del )]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 383.486 181.0625 Tm 0 Tw (paciente)Tj ET EMC /Artifact <>BDC .617 w q 1 0 0 1 383.486 180.037 cm 0 0 m 34.767 0 l S Q EMC /P <>BDC BT 9.25 0 0 9.25 418.2526 181.0625 Tm .0886 Tw [( para la revelacin de expedientes de)]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 575.975 181.0625 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 171.0624 Tm -.0028 Tc .0278 Tw (salud mental si la persona tiene ms de 12 aos pero menos de 18 aos de edad\).)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 377.9858 171.0624 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 161.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 151.0625 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 141.0624 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 348.0208 141.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 384 141.0624 Tm (Fecha: )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 417.5551 141.0624 Tm (_____________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 566.743 141.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 569.5699 141.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 131.0625 Tm .0278 Tw (Firma del testigo )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 107.7132 131.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 121.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 111.0624 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 101.0625 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 348.0208 101.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 384 101.0625 Tm .0278 Tw (Nmero de telfono:)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 472.2563 101.0625 Tm 0 Tw (___________________)Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 570 101.0625 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 91.0624 Tm .0278 Tw [(Nombre del testigo en LETRA)54.7( DE IMPRENT)73.7(A)54.7( )]TJ ET EMC /P <>BDC BT 9.25 0 0 9.25 227.3382 91.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 81.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 71.0625 Tm ( )Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 37.5528 61.0624 Tm (_______________________________________________________________________)Tj ET EMC /P <>BDC BT 7.8625 0 0 9.25 348.0177 61.0624 Tm ( )Tj ET EMC /P <>BDC BT 9.25 0 0 9.25 36 51.0625 Tm .0278 Tw (Indique la relacin con el paciente)Tj ET EMC /P <>BDC BT 7 0 0 7 36 35.7499 Tm [(MR1928-SP)17.6( \(1)73.7(1-13-25\))]TJ ET EMC /P <>BDC BT 7 0 0 7 111.7554 35.7499 Tm 0 Tw ( )Tj 35.2847 0 TD ( )Tj ET EMC /P <>BDC BT 7 0 0 7 526.0029 35.7499 Tm .0278 Tw [(PGINA)54.7( 2 DE 2)]TJ ET EMC /P <>BDC BT 9 0 0 9 36 698.25 Tm [(P)73.7(A)73.7(TIENT)17.6( NAME)]TJ ET EMC /P <>BDC BT 9 0 0 9 105.8174 698.25 Tm 0 Tw (__________________________________)Tj ET EMC /P <>BDC BT 9 0 0 9 276 698.25 Tm ( )Tj ET EMC /P <>BDC BT 9 0 0 9 36 674.25 Tm .0278 Tw [(DA)73.7(TE OF 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