EFTA00292239.pdf

UNIT EOHEAL THCARE P 0 GOX 740800 1500 ATLANTA GA 30374 HEALTH INSURANCE CLAIM FORM 9 . 4, o•tart ILL N --..:1:A/[ A"'".'et' I • 4•0. 444 4 %. -...,• ' nit e raliria• O!..t. is 042,40_Ct •AA4t. ottA • IC. Nic nr. "..11/44 ACMitt With ' 854905597 t 144.A4441 I Aisne 921,„_*" • 4'. tio.•4 I.• •0 t7 ,imakr• • tfa•Am OM - a tan VI Mak 444 ••11.1rw Mai I ciihrot thAnD41"3 *ace liters EPSTEIN, JEFFREY EPSTEIN. JEFFREY pLA 3• • _ • nikatifittAr.mmt sTiej cower rkimer ahron• • •414 44-1 sass I. 44 sog 9 EAST 7IST STREET _ 9 EAST 71ST STREET • ctMt 41- tiMr•t-7+50* 14 NY NY NEW YORK NEW Mo. cid -10104704tarcum It I . ••,...A I..4• :cc.4 10021 1CO21 iDATOAAICIO-: to • eitialikaitia Matto to .. ADAC 0 441.<4 44004:64 • Z•wilil / 3.-• Z J 'Oak ran I14 Ian. h.• 2;7605 • Kneen paw on — lel GWAA' MAWR • I luratOat4. 4.4•44 • Petwasj ow co Iv •;114;10V-CN Wei , Oft_ _ 20 1953. • t at so to trIcrin. e.ta 'Oat 01 ;loyea•fatil./.WlT0•46— X 4D _ kr.:aitiaaliPki lia --- -, ono act COW aat • al it IC UNTTEDHEALTHCARE 4 WitioWeS 44:44i.a v. NO4,a.. onat e..Cm'eSi4o — 1 34/ ti44a.aPaaaral@The1490-47VW-- K3 LIL NO las 1.0•Ii• •••• Is Aga Wei oi NAY Watt ON" t 0.44.140 Isle IOW It 00441 awfulaiTharn hTe- ill a Auttareitialastals--- ••••••••••) Per tams Wormr vs ~one span or • At attars & AO:Walt 4tta.te tat On A roe ,. •••• 4•4,.. 4.4. -not ~-4..4 crew. 4.440'4, a 4. n 44.4. Asia **ern doetriatro• [ tem wan° SIFIAIUM 071 61• tars 04 08 2016 DtMO • - 1111. tot NI I. • OWL, ttp Y MOW DO TT M INI CA/41. ig‘ as -- • WOO/ ODTRA*4 araeigica r ft 01 tat ( a *calora tIltiTaretra MU te0 :1) zuscez.sa. trdiTtnia ID at Ott at ;,-Atitititt i Cyle.arISABESI ,t ' ii AZISTOVortai AGIMA0 0i3iireiliarital ta.inr,≤ - Nil g... • i il• WAS IA *Attar (74 1:440 NI lateti747arti -sinVo 1W•••:-.094t hT. a - ir , 77 WILESICA titiVAAt an 40 A . 214C a _ TWO __ C 0 - H i.____ ilii64 4;abir C 4 . : — iall I I 1 • .4 • clAtirs: 01 Ile/AOCI ,. W pea H IN li : i 42.A.. ti Y. 'WWI ' tit: 1 t rcliplail "vas all Eipt4t..4.... 7 :ettrJeCt ilint. 177. --.1.3 tla rICCIV Th oconch Iowan . I : 11,..1., .•4 t, ;4 :7 „,..„0„,„....' t-..- ' '/..'• I •"1 1. Oa .. bi;. te 36 cCaOtt- Is • 11 - 74 922 14 25 • A 6cio—iio 1 . iail hiiiiiiiiiiii-- - : ... 15 CA Oil 15 II 17000 _ , 04 et PI _ . 8 175 CO 1 . wig.1. t02213-62.il t/P1 — EVA [ 1 WI ,- i I osibiailes-Liaar kvi , 4 4, —Jo Alia :::t •. • - ' NPI tt.. 133143772 • 675 00 a t WIIIIInnabai• Vin fi — tlfltiMer OURS tin 676 00 I COMM 04 OlittwOall I Macho A kIlato ItQ • ,I w...mu-WOgnu 21-2- 0 es at to arm Po ••• ....• eh•• yr ono L MI ItHELL A KI.IP•IE MO PC lererr4 Li 703 Pm• Ms Ks,irk MD PC 700 PARK AVENUE Nat York NY 10021 04 OS 2015 tIEW YORK NY 10021 tguicti ti • bin fateast apps, pa has 0040aral tar ISM tile MI EFTA00292239 HI Statement of Account MITCHELL A KLINE. MD PC 700 PARK AVENUE Date ACCOtrft, Y RK NY 10021 0000001 E 0403/2015 Last PAY-client JEFFREY EPSTEIN a ?TOO N 9 EAST 71ST STREET NEW YORK, NY 10021 04(0E/2015 Paid by Paid By Description Charges Insurance Patient Date Procedure lien III. 500.00 500.00 04/08/2015 99214 Est Pt Vis4 Dstatled 175 00 175.00 at/08;201s 17000 Dest SentPremalg 1st :• 4.1 n. - - 0 -30 Days 3 - 60 Days 01 - 90 Da9191 - 120 DayslT 120 Days POWS 1 Currant , Peal Dab Past Due Past Due Past Due B11011060', —T 3000 SO 00 I SO 00 SO 00 $0.00 SO DO CUT 014 conEl) ONE AND SEND WITH PAYMENT Notes: EPS1EIN, JEFFREY FOR BILLING INQUIRIES CONTAC ACCOUNT NO. 0000008048 Statement Date 04/08:2015 Please remit payment of $0,00 payable to; MITCHELL A KLINE. MD PC EFTA00292240  MITCHELL A KLINE MU PC 700 PARK AVENUE NE YORK. NY 10021 Merchant ID: 000051193746 Term ID: 51193746 Ref P: 0002 Sale mama AMEX €ntryMethod:Sniped Total: $ 850,00 04/08/15 11:07:29 Inv4: 000002 APPrCode:527907 : ine APPrvdOnl Batchif:000946 Customer COPY THANK VOW EFTA00292241