EFTA00316208.pdf

Statement of Account MITCHELL A KLINE. MD PC Date Account No. Page # 03/30/2016 0000008048 1 JEFFREY EPSTEIN Last Payment 9 EAST 71ST STREET Date Amount NEW YORK. NY 10021 04/08/2015 675.00 Paid by Paid By Date Procedure Description Charges Insurance Patient Adj. Balance 03/30/2016 99214 Est Pt Visit Detailed 450.00 450.00 03/30/2016 11100 Biopsy/Skin, 1st 250.00 250.00 03/30/2016 17000 Dest Ben/Premalig 1st 175.00 175.00 03/30/2016 17003 Dest Ben/Premal 2-14 150.00 150.00 03/30/2016 96904 whole body integumentary photograpy 500.00 500.00 0 - 30 Days 31 - 60 Days 61 - 90 Days 91 - 120 Days > 120 Days Pat ent Current Past Due Past Due Past Due Past Due Balance Due $1525.00 $0.00 $0.00 $0.00 $0.00 $1525.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT Notes: EPSTEIN, JEFFREY ACCOUNT NO. FOR BILLING INQUIRIES CONTACT 0000008048 Statement Date: 03/30/2016 Please remit payment of $1525.00 payable to: MITCHELL A KLINE, MD PC EFTA00316208  From: Subject: Jeffrey and dWM, or 2016 Date: March 29.2016 at 11:39 AM To: Bella Klein FYI...Jeffrey is going to see Dr. Magnani tomorrow at 9am and Dr. Kline at 10am (Magnani for a cavity and Kline is a dermatologist) EFTA00316209  Statement of Account 2pa D PC JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK NY 10021 Date Procedure Description Paid by Paid By Cha es Insurance 03/30/2016 99214 Est Pt Patient Adt Balance Visit Detaned 450.00 03/30/2016 11100 Biopsy/Skin. 450.00 1st 250.00 250.00 03/30/2016 17000 Dest B en/Presiali9 1st 175.00 175.00 03/30/2016 17003 Dest EieNPrema12-14 160.00 150.00 03/30/2016 96904 whole body integumentary photograpy 500.00 500.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT ,JEFFREY Notes: ACCOUNT NO. FOR BILLING INQUIRIES CONTACT 0000008048 Statement Date: 04/07/2016 Please remit payment of $0.00 payable to: MITCHELL A KLINE, MD PC EFTA00316210  ergs:// tnercha ore enlercardcolineage nilaccountIrece p#R0 984906$: MITCHESD PC 04/07/2016 0255:28 PM Ref #. 0984906537 55 Authorization Code: 12 3648 Total: $1,525.00 use Card Number. 37Z0000000 (3001 Card Holder. JEFFREY EP STEIN Question about this rec eipt? Call us at O 2016 MITCHELL A KLINE MD PC . Wt rig hts reserved. ( 417120162:56 PM EFTA00316211  VMS, J HEALTH UNIT INSURANCE CLAIM EDHEALTHCARE APPROVED ay NACONAl. FORM P 0 80X UNWORN CIA& CO44545F54 5' IN 740800 MCA 0502 ATLANTA GA 30374 I. t CAR CHANPVA (54ZnanTiritiekeasitEL(Soomer• Sria MN.* PLAN taw s let8ER PICA EPASTEIN, JEFFREY PATENTS 854905597 (For 'wens, o ma."'" 5441 9yDAT 4. IFAsuR OS 40.• mike - 01 20 1953 ax I9 EAST 71ST PAT Name.IN" 49 STREET SHIP EPSTEIN, JEFFREY i 440 SOO499 (A' u A • 4i fr-- I NEW YORK ----- 11Y R ERVE FOR Oes — IILICC 9 EAST 71ST STREET 1.~r----- I NY - ---ritiml~~---1 ;10021 i NEW YORK STA j i~AiStiREDSNA i NY . IRc 10021 12 / 8 Q.10) I -____ lasS° A; —1 -1° 4 it *NUR PS I 0550-- .91 ePa~ I P-A~E--"A 4.1 -- a DIPLOYMENT? (Cinr4 272605 UP OR CA crPT991fli REIERVED FOR NUCC 0SE DM ®No MM 00 rr SEX b. AIJTO ACCIDENT? 01 20 iorninufgrerm or_________ G'Ili DD NOPVC& MORN 0. 5SprananQ 1953 A ) c. OMER ACCIDENT'? 1_,J YES Latialer~ UitAA NAME "--6MCMirjr"-- IyjNO UNITEDHEALTHCARE is IS THERE MIOIWTRar I ---- I IX PATIEWTS OR AUTHORIZED --19F-45—n~Cairenbiarahre9114~;37511 -6TOTt41 1YELialt 10 . Ir Yet ~A klieg 0. 94 Toxin TOprouit ID* ctlim9 PERSON'S SGNATuRE I 09.99~ thø -- — I I &so N944) pirTmin SIGNED Signatufe on file Dini• d or0 m•ilicei ix oft inkenuoon 44~rain Porisit. 0~99 T97944 or 99 IN, Tots van way 494•9010* ~ant 13 INS OR POr~ Of ~al AUTIONDEO PARSONSnj ~is to ZS until:awedaiii sev,an &sots° bibs —--- TuRE /aanna itemcan acipierke N DATE O4 07 2016 CO r4 or PR N SIGNED itt USA 1.04441 f1 . QUALI FR 504 OD 44 0 K CLIRRDTTOCC PATON MMMM DO OF FERRINc PkniCini OA OTHER SOUR c TO IYAYpN ua ris MI6, /ORAL Italia' i „___. TA WA CO YY 'Aril or Not WORM.* ION <0~4 T i TO • OUTS0E LAC* 5 CHARGES r iT.-5~e NA 54XNES R iNJURnTriiiin YES Wrap 1 it A. L0225 _ Ito iniii ( g581,444ssicie 8 I 0485 c.i I-510 I ORIGINAL RIT4 NO PL._ EL F.1._.- 0• `_ H. AUTIRRIZATION NUMBER L K I. 24 A. DAM) OF WNW! B. D O. PROCEOURES. SERvICES. OR SUPPt C. F. G. N I. J P.S. TO PLACE (41:4199 UrmiNal CA~TITACT•) DIAGNOSIS Da n ',CPm a /0 OA RU4012/bia) SA 00 WMIA 00 1•I SCR= EMG CPTAICPCS MOWER POWER $CIIMGES QUAL i i A 450 00 NPI 1932136231 03 30 16 I 30 16 11 N 11100 59 B 250 00 1 NPI 93 138231 NPI 19 21 16 03 30 . 18 11 17003 180 00 3 NPI 19321 1 ' 11 00 1 NPI 1 231 NPI PATIENTS ACCOUNT NO. . k ‘r.orgrjAISID904%tir 20 AL CHARGE 29 PAP TO R•941 NVCC Uu FE00441TAX WOMEN — GU 133843772 0000008048 yes NO $ 152500 $ 1525 00 .3I SIGNATUR< OF PrPISICIAN CR SLR RVICE TA iLI L 212 5178555 INCLUOIKO DEGREES OR CREOENDALS li A Kline MO MiTCHELL A KUNE MD PC il 4•544~ Or 90444.44.4 Ont.mina «ofIo Nis Oil end aromas pert 'Direct) MITCHELL A KLINE MD PC 04 07 2016 $1154419318 a 41154489318 D. WNW OAT! ACCICIPIUCA `.. . . Iie WO (02)12 NUCC InStruction Manual available at minv nue.CONI EFTA00316212