EFTA00312739.pdf

meet Mart magic. Structured Healthcare . Management, Inc. JEFFREY EPSTEIN 1 STATEMENT DATE AMT. ONE MOM ranter ACCT NO. 01/09/2012 30.00 053177 A Ct REOUESTED Office PhoneMM. AMOUNT ENCLOSED: MAKE CHECK PAYABLE TO: N Y NEUROLOGICAL ASSOCIATES,. ATTENTION GHI INSUREDS ONLY: AS OF JANUARY 2001, NY NEUROLOGY NO LONGER PARTICIPATES WITH GHI. CALL EON REGARDING YOUR REIMBURSEMENT. YOU MUST PAY THIS BILL. ,,,,,Irlitilli III 11111111 II 11111 IIIIIIIIIIIII IIIIIIIIIIIII 11116111 IIIIIIIII III. IIIIIIIIIIIIIIII 003372 0.5380 AT 0.365 JEFFREY EPSTEIN 9 E 71ST STREET IIIIIII NEW YORK, NY 10021.4102 =I= Please contact our billing office at 800.3949201 if your address is incorrect or insurance information hes changed. DETACH HERE AND RETURN THE ABOVE PORTION %ITN YOUR PAYMENT N Y NEUROLOGICAL ASSOCIATES,.. PATIENT INNS FON WPAINElleati 162 EAST 78TH STREET JEFFREY EPSTEIN NEW YORK, NY 10075.0406 ANOMIE MAIM SEAT WANT DAM PAO( isrmila 053177 01/09/2012 1 DATE DESCRIPTION DAYS/ SERVICE FROM TO UNITS AMOUNT CHARGES PAYMENTS BALANCE 12/27/11 Portion not paid by insurance (FORM A1B45) 30.00 30.00 For Services: 11/21/2011 • 11/21/2011 Coins-330.00 12/27/2011 CO-PAY FOR DATE OF SERVICE 11/21/11 IS $30.00 ACCOUNT BALANCE 30.00 MESSAGE PROMPT PAYMENT IS REQUESTED: AMOUNT DUE AMOUNTDUE 30.00 STATEMENT OF ACCOUNT + DuctumE Healthr..va Manegornenl. inc. Er ;.cwooT. Nom JerSey 07631 SHAli•T 123110O3372 0001 EFTA00312739