Exhibit 24

2:14-cv-11700-PDB-MJH Doc # 1-25 Filed 04/29/14 Pg 1 of 4 Pg ID 293
2485838969 IMAGE CENTER 110805a.m 06022011 13/16

PICA

1-

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LII

It

HEALTH INSURANCE CLAIM FORM

APPROVED DY NATIONAL UNIFORM CLAIM COMMITtEE 08/05

iPICA

STATE FARM

P.O BOX 2361

BLOOMINGTON IL 61702

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OThER la INSUREDS ID NUMBER Pot Program lIem

CHAMPUS HEALTH PLAN 811 LUNG

MocLrcareWMSicerd SpcnsafaSSN 4mbailL3e9SSNntIO flSSN ao 220440773

PATIENTS FLAME LanI Name FirM Name Middle lerlial PATIENTS EIRTH DATE SEX

MM nfl vv

PA ION AUtSS INS SIOII PATI RELATIONSHu-TO INSURED

INSUREDS NAME LesI Name Pita Name MrddIe India

SAME

INSUREDS ADDRESS No Streel

L.Jncn LnpJnnUpriPiMn LunL udrm renl name rinaure Inmall

SoIl SposeeD ChIIdfl Other SANE

PATIENT STATUS

Single fl Meroed Olher IKI

Full-Time rm Pail-Timeri

Employed L.i Stadeel L..J Sluderd L_J

10.15 PATIENTS CONDITION RELATED TD

CITY STATE

ZIP CODE TELEPHONE Include Area Code

11 INSUREDS POLICY ORDUP OR FECA NUMBER

OTHER INSUREDS POLICY OR GROUP NUMBER EMPLOYMENT Current or Previsue

DYES ND AUTO ACCIDENV

PLACE Slate

EYES DND 1I

OTHER ACCIDENT

DYES NO toil RESERVED FOR LOCAL USE

INSUREDS DATE OF BIRTH SEX MM DD YY

OTHER INSUREDS DATE CF BIRTH

MM DD YY

EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

IS THERE ANOTHER HEALTH BENEFIT PLAN

DYES NO It yes relurn to and complete IIem 984

IS INSUREDS DR AUThORIZED PERSONS SIGNATURE eulholoe

peymenl of medical benelile lathe undersigned phyoicla.n or ooppller lot

Services described below

SIGNEO_

2-IGNATURE --ON FILE

EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

READ BACK OF FORM BEFORE COMPLETING SIGNING ThIS FORM

12 PATIENTS OR AUThORIZEO PERSONS SIGNATURE aelhadze Iho releaee at any medioal or other Intormellen neceasery

to process this claim also request paymesl of gouermnent benehle eliherls myseft or to the patty who eccepla assignment

below

SIGNATURE ON FILE -- mssvu OATh

CURRENT ILLNESS First symptom OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

01Y1 INJURY Accident OR GIVE FIRST DATE MM GD YY

PREL3NANCYLMP

16 DATES PATiENT UNAELEI WORK IN

MM 00 Cj3JNT %O0OIWATIONYY

FROM TO

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE

TAMES BEALE DO t7a flYi4Io OD YY MM DO YY

16

HOSPITZATION

DATES RELATED TO CURRENT SERVICES

PROM TO

16 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

LJYES rJNO

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Eams Sor to Item 24E by LIne

2.L__. 4.L__

22 PAID RESUBMISSION

ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

24 DATES OP SERVICE PROCEDURES SERVICES OR SUPPUES

Fiom To IPL8cEII Eaplain Unusual Chcarnslanaea DIAGNOSIS IMYS th 08 lFerr MM DO YY MM 00 YY IsuRVICEI EMG CPT/HCPCS MODIFIER POINTER CHARGES HiS Pan

fO512d11 Ill j70551 5400401

OUdL

NP

RENDERING

PROVIDER 10.1

It

2Ii Iii

NFl 34111 __I I.L en

It ii .1 NPI

Ii II HR

I.IlI 25 FEDERAL TAX 1.0 NUMBER SSN EIN 26 PATIENTS ACCOUNT NO 27 CCEPTASSIGNNT 28 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE

lflflVlflflfl4 flYES flNO ç4flflflfl

31 SIGNATURE OP PHYSICIAN OR SUPPLIER

INCLUDING DEGREES OR CREDENTIALS

cattily thai Ihe alalernenle 00 Ihe reverse

apply Ia thIs sill ens are mass pail Iherusl

/IVER SEHOAL MD

SIGNEDOG/0112011__DATE

32 SERVICE FACILITY LOCATION INFORMATION

THE IMAGING CTR

15670 $OUTHFIELD PD

IAT1LEN PARR MT 4fl012c1%

In

33 BILLING PROVIDER INFO PH 48SB3 8922

IMICH IGAN BIOTECH PRTNRS

30781 STEPHENSON HWY

MAflTSON WIS MT 4R071-161S

Ha1921o95472fr$2300170094

aNIJCC InstruCtion MSrIUS availabe at www.nUOC.org PLEASE

MId by Medical Aria Press

Call toiltree r-800-S28-21 78

PAINTOR TYPE APPROVED OMB-0938-0999 FORM CMSl 500 08-05

014710- Mrdicel Arts Press

Usa mbA Envelope aI4t4S 5snlmnd or 014146 sell oeal

2:14-cv-11700-PDB-MJH Doc # 1-25 Filed 04/29/14 Pg 2 of 4 Pg ID 294
2485838969 IMAGE CENTER 111058am 06022011 15/16

MRh/MRA

Imaging

Centers

EXAM DATE

PATIENT NAME

PAtIENT ID

LOCATION

05/31/2011 113319

IVF4QV

THE IMAG1NG CENTER

02c 110773

SEX

DOS

F-ERRING PHYSICIAN DR BEALE

tAAMINATION

FINAL REPORT

The Imaging Center

15610 Soutbftetd Rcad

ALLEN PARK Ml 4816

3131 294-280

FAX3I3l4 2915

CLINICAL HIS TORY

43 year old male with MVA and now complaining of frequent intermittent throbbing pain to

temples Dizziness lightheadedness and short term memory loss

MR IMAGING PROTOCOL

Mo-Magnetic Resonance Inc

Multi-planar multi-sequences MR images were obtained of the brain No similar previous

S... 4..__ AL

ROSEVILLE.Ml48066

Mn 4454

FM 5861 44fi4932

Diamagnetic Imaging Center

960 River Cenlre Cure

PORT HuRON MI 4808c1

81610664523

FM 11 61 EN-6Cc56

The ImagIng Center

4447 Iahnadgc 8mm 11

TOLEDO OH 43623

674 8351

MX IfiwIsl744swZ

68 MRlTODAY

6144832

mrwbtnIuaimi CCII

MR FIND1NG$j

Diffusion weighted images show no restrictive diffusion abnormality to suggest an acute

stroke or bleed The cortical volume is normal The grey-white differentiation is normal

No significant white matter abnormalities are seen

T2 diffusion tensor imaging is normal

The lateral ventricles are normal in size and symmetric bilaterally The 3rd and 4th ventricles

are midline The rest of the subarachnoid system Is within normal limits Normal vascular flow

voids are seen The sella and paraseliar regions are normal The craniocervical Junction is

normal The calvariurru skull base and soft tissues of the scalp are normal The vlsuaflzed

orbits are normal

inflammatory changes are seen in the frontal bilateral ethmoid and maxillary sinuses The

mastoid air cells are almost completely opacified bilaterally

Dictated Sehgal Vivek MD 06/01/2011 0256 PM

Transcribed Solomon Peggie 08/01/2011 0405 PM

Electronically signed Sehgal Vivek MD 06/01/2011 0434 PM

Rio.Magneiic Resonance Inc

36181 Stcphvnsnn Hglnvay

MADISON HEIGHTS Ml 46071

248m S855I IS

FM /481 MIS 0134

BRAIN MRI WITH AND WITHOUT MAGNEVIST

2:14-cv-11700-PDB-MJH Doc # 1-25 Filed 04/29/14 Pg 3 of 4 Pg ID 295
2485838969 IMAGE CENTER 11159a.m 06022011 16/16

110$jggfletiC

MRh/MRA

Imaging

Centers

EXAM DATE

PATIENT NAME

PATIENt ID

LOCATION

05/31/2011 113319

1707460

THE IMAGING CENTER

22 j19773

SEX

DOBj

Otomaqoelic Ima9tng Center

114 finer Centre Uuve

PORT HURON Mt 4/cOot

BiGflaSZa

Ac8tmc66.956

the Imaging Center

.1417 Tatmalqe Suite It

TOLEDO OH 43623

18883674841

ri

Dictated Sehgal Vivek MD 06/01/2011 0256 PM

Transcribed Solomon Peggie 06/01/2011 0405 PM

Electronically signed Sehgal Vivek MD 06/01/2011 0434 PM

Rio-Magnetic Resonance Inc

30701 Stephenson Highway

MAOISON HEIGHTS Ml 46/lit

t24t 583-MIS

112183850234

The Imaging Center

15670 SoutRtiold I/cad

ALLEH PARK Mt 48101

313 294-0/

FMt3t3y201-2915

Rio-Magnetic Resonance Inc

IMPRESSION

No significant intracranial abnormalities seen

Sinus disease in the frontal ethmold maxillary sinuses and bilateral mastoid

inflammatory changes

Thank you for your referral

ROSEVILLLMlSOSl

1588 445 ltXX

fss6l44s4qo

888 MRI-TOI3AY

614.8632

wwwkiotnaqwnlcOcti

2:14-cv-11700-PDB-MJH Doc # 1-25 Filed 04/29/14 Pg 4 of 4 Pg ID 296