EFTA00292227.pdf

Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 ingatMli WAregiiiiNOSIN .R. 02/26/2019 0000008048 1 JEFFREY EPSTEIN trallipaMOVONO 2ffilf it, a 9 EAST 71ST STREET Brattogiagt cg NEW YORK, NY 10021 08/10/2016 I 875.00 Paid by Paid By Date Procedure Description Charges Insurance Patient Adj. Balance 01/11/2019 99213 Est Pt Visit Expanded 93.41 93.41 01/11/2019 17000 Dest Ben/Premalig 1st 84.24 84.24 01/11/2019 17003 Dest Ben/Premal 2-14 22.23 22.23 kivt t/9 i dA 6 ti •iz - e`)C. ry• Oil . 446 Cu 0 .6s4A j - . :onto 74.1.,Rurarm At.7.,Eirrioa reviewers mat tatyr !feysclikelit bi-:jai/001e ViiiiSfitia ilislirs*itiliteAtt,tpi $0.00 $199.88 $0.00 $0.00 $0.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT Notes: EPSTEIN, JEFFREY FOR BILLING INQUIRIES CONTAC ACCOUNT NO. 0000008048 Statement Date: 02/26/2019 Please remit payment of $199.88 payable to: MITCHELL A KLINE, MD PC EFTA00292227  Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK. NY 10021 Date L Account No. Pa•e# 02/01/2019 0000008048 1 JEFFREY EPSTEIN Last Payment 9 EAST 71ST STREET Date Amount NEW YORK, NY 10021 08/10/2016 875.00 Paid by Paid By Date Procedure Description Charges Insurance Patient Adj. Balance 01/11/2019 99212 Established Pt Visit Straightfwrd 250 250.00 01/11/2019 17000 Dest Ben/Premalig 1st 25'.00 250.00 01/11/2019 17003 Dest Ben/Premal 2-14 50.00 150.00 A Gate- 1,,ni- efruct, ivtt 0 04- vt el tecil 4 -c c) 0-- v IA) i r L 0 - 30 Days 31 - 60 Days 61 - 90 Days 91 - 120 Days > 120 Days Patient Current Past Due Past Due Past Due Past Due Balance Due $650.00 $0.00 $0.00 $0.00 $0.00 $650.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT Notes: EPSTEIN, JEFFREY ACCOUNT NO. FOR BILLING INQUIRIES CONTACT 0000008048 Statement Date: 02/01/2019 VISA MC AMEX Please remit payment of $650.00 payable to: Acct.*, Exp. Date Signature EFTA00292228  Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK. NY 10021 T7:Thr 4 :4 4 Atairalel0 02/26/2019 0000008048 1 JEFFREY EPSTEIN pipag„. L-Lttisatierste 9 EAST 71ST STREET "Ss.. tip' W a rs. • . L.. • NEW YORK, NY 10021 08/10/2016 875.00 Paid by Paid By Date Procedure Description Charges Insurance Patient Adj. Balance 02/26/2019 99212 Established Pt Visit Straightfwrd 57.27 ....- 9tti )441 14- ed 40 44,e th2e57.27 02/26/2019 A92705ELECTRODESICCATION 350.00 /,42 d- nA edic-ae 350.00 rrilt: . 4 !DOA% al." a s- Da iDa s . 1,2p D 6 p.„ ka.__m i rr z - pagigy, " anti 4341 16V1 Eintkl .a ..__.'as Due jelfa nata _ as , ?At n,..eaa $407.27 $0.00 $0.00 $0.00 $0.00 $407.27 CUT ON DOTTED LINE AND SEND WITH PAYMENT Notes: EPSTEIN, JEFFREY ACCOUNT NO. FOR BILLING INQUIRIES CONTACT 0000008048 Statement Date: 02/26/2019 Please remit payment of $407.27 payable to: MITCHELL A KLINE, MD PC EFTA00292229