EFTA01122978.pdf

STATEMENT Thomas J. Ma nani Alvin Gra son If Dung by endA cad. enter Na A-11MM you St CW00 r, Ma ""Zteva box 0,4 Ail Out below maskers/0 VLLe ____ Max CAM if En Dale Sc,. ,,, OP Code Mr. Jeff Epstein Date Account 9 East 71st Street 1/7/2015 9293 New York NY 10021 Remittance IMPORTANT PLEASE DETACH UPPER PORTION ANO RETURN Mill YOUR REMMANcE TO INSURE' CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 Previous Balance 0.00 1/6/2015 40.00 40.00 1/6/2015 180.00 220.00 1/6/2015 600.00 820.00 Account Total 820.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the top part of this statement, or call the office a Current 30 Days 60 Days 90 Days 120+ Days 820.00 0.00 0.00 0.00 0.00 i Thomas J. MagnanIM. Mtn Grayson-. EFTA01122978  Thomas J. Ma • TelephonE Alvin Grayson per; by twit cwt. enter Mt mount you so POW( Saul below Masten:DM Vest Amax Coda Slutture Mr. Jeff Epstein Date 9 East 71st Street 7/29/2015 New York NY 10021 IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR RIENTTANCE TO aasuaa CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits 7/1/2015 J . 4• •ce 7/1/2015 40.00 7/1/2015 180.00 Account Total If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 1 220.00 0.00 0.00 0.00 Thomas J. Magnant.l. Alvin Grayson.. EFTA01122979  STATEMENT Thomas J. Ma Alvin Gra son Par, n0 by CroSi ord. only to ernaxI yea: ara Par4^9 Inr'e romitonc• WI end 14 out Won. Itestettrrd 1s Pena Cwda Exa Oita Scaturo Sig Cole Mr. Jeff Epstein Date Account 9 East 71st Street 3/2/2016 9293 New York NY 10021 Remittance IIIPORTANT - PI FACF DETACH UPPER PORTION AND RETURN WTH YOUR REIATTMVE TO TISURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 1/27/2016 nce 0.00 2/17/2016 40.00 40.00 2/17/2016 180.00 220.00 Account Total 220.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may comple p part of this statement, or call the officetiiiiiiiii Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Paagnanl =. Alvin Grayson-. EFTA01122980  STATEMENT Thomas J. Ma . Alvin Gra son IImina by artell cent enter Ile ert16., 4 you on fl ing In Pto rernierneto Nee and fie cabelcw. Mmtercard Vaa Amax Cord • Tv Date Sgvlua SO CO:e Mr. Jeff Epstein Date Account 9 East 71st Street 3/30/2016 9293 New York NY 10021 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN LATIN YOUR RENUTTNCE TO P4SURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/2/2016 220.00 3/17/2016 220.00 0.00 3/22/2016 125.00 125.00 3/22/2016 30.00 155.00 3/22/2016 450.00 605.00 606 Account Total 605.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the to • •art of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 605.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl Alvin Grayson M. EFTA01122981  STATEMENT Thomas J. Ma Alvin Grayson IT parity midi Taft nil. Maya MN Ere psylng MEE nmilammi box • ad META Flasined NM Mat Cede Exp Dill Scan SiDade Mr. Jeff Epstein Date Amami 9 East 71st Street 10/29/2015 9293 New York NY 10021 Ramitanee IMPORTANT - INCASE DETACH LETITCR PORTION MID RETURN WIN YOUR REMITTANCE TO EPSIJRC CRUET TO PROPER ACCOUPR Date Patient Description Charges Credits Balance 9/30/2015 Previous Balance 0.00 10/612015 450.00 450.00 10/6/2015 450.00 900.00 10/13/2015 275.00 1,175.00 Account Total 1,175.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and r turn et part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 1,175.00 0.00 0.00 0.00 0.00 Thomas J. /Mona&Nu Akin Grayson EFTA01122982