EFTA01085315.pdf

02/11/2016 13:34 MUSIKANT DEUTSCH PC PAGE 01/02 PRACTICE LIMITED TO ENDODOMIC3 STEVEN D KAPLAN, D.M.D. ALEN 4K0B, D.M.D. PRACTICE LimIrmo TO ENOODONTICS 119 WEST 57 STREET SUITE 700 C. NEW YORK. N.Y. 10019 FAX CO ER LETTER Date: c;- IL Lk To: 2 ( it i From: ;( k :-,(eiLJ“ ---31 ../ .i, cr:› Number Of Pages Including This Cover Sheet Comments: I--s\!; ._ 17— #(17--, CCOICLALVZ-51C DNS " L- 12-• CA- C--ap t-1 .-1 1C1 -4 011.1-et/t. OtfrCW, -_--i---- cei,.4 EFTA01085315  02/11/2016 13:34 MUSIKANT DEUTSCH PC PAGE 02/02 PATIENT rParto- arsteast DATE Steven D Kaplan, DMD 119 West 57th Street 02/11/2016 Suite 700 nal New York NY 10019 PATIENT DESCRIPTION CHARGE CREDIT EXPECTED INS PATIENT CHARGE 25C0.00 .00 2500.00 02/11/2016 Steven L'. Kapian Ta.x ID. 13 3 3 161736 LIC. 03416: SUMMARY INSURANCE PATIENT ADDITIONAL iNFORmATIOWAPPOINTMENT SCHEDULING PREVIOUS ACCOUNT BALANCE .00 .00 CHARGES FOR TODAY'S VISIT .00 + 2500.00 PAYMENT .00 CURRENT ACCOUNT BALANCE .00 2500.00 TOTAL OBLIGATION 2 500.00 PLEASE PAY THIS AMOUNT --> 2500.00 If your insurance company pays more than evaded, you win be credied the difference. It your insurance company pays less Than expelled, you will be charged the difference. Final nesponsibdity for payment refits with the person to whom this receipt is addressed. EFTA01085316