EFTA00317363.pdf

MARC S. LEMCHEN DMD, PC PATIENT NAME PATIENT N DUE BALANCE NEW YORK, NY 10065-8108 590.00 590.00 FOR BILLING INQUIRIES: PAGE: 1 of 1 AGING AMOUNTS: IIrIIIIIIIIrIIIIIIIr i llII 'hill.. 'IllIli! 'lir 0-30: 590.00 31-60: 0.00 JEFFREY EPSTEIN 61-90: 0.00 301 EAST 66TH ST APT 11P OVER 90: 0.00 NEW YORK, NY 10065-6217 328951•CAOFAARM200258 DATE TRANSACTION PATIENT NAME AMOUNT Previcais_Balance: . 0.00 4/6/2015 EXAM/RECORDS/ADULT 495.00 4/7/2015 Radiology Report 95.00 fM . Of, NIL . ID . Al It ti nit i I IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW. PATIENT NAME PAT. At DUE PAID CtIECX CARD USING FOR PAYMENT 590.00 MASTERCARD = O DISCOVER AMERICAN EXPRESS CARO M.IMBER =NATURE CODE SIGNATURE EXP. DATE STATEMENT DATE PAY THIS AMOUNT ACCT. It 5/1/2015 $590.00 Epstein, Jeffrey P:ease check box if your address b incorrect or 32895 SHOW AMOUNT $ I—I has changed, and indicate changeb; on reverse side. PAGE: 1 of 1 PAID HERE 1501558 000590 owl JEFFREY EPSTEIN NEW YORK, NY 10065-6217 54108 IIIM1110111 1 11111 II 111111111 11 32895•TCAOFA4RE00258 EFTA00317363