EFTA00299760.pdf

rindbe return lap pOrtfOn with your payment addressed to: receipt Receipt date 09/15/2017 STUART I. ORSHER. M.O.. P.C. Patient accounts 010224 OIPLCHATE. BOARD INTERNAL HEOICINE Patient name 9 E 79TH ST JEFFREY EPSTEIN Amount due $ 0.00 NEW YORK. NV 10075-0123 Office p1mw 212-535-1763 Amount unclosed S '=EASE., JEFFREY EPSTEIN RIITATEEKWIWOINVP6fitnF''34'YOUO J4Kb/B11"11"1 9 EAST 71ST STREET EIZRE4 svo 627-ow 7.., i, E\TH.:.1 NEW YORK, NY 10021 PATSTNT REOLESTED TINE PLEASE REtBIN'TRIS PORTION POR TC-JR TAX RECORDS Please indicate any corrections to your address. Receipt date 09/15/2017 STUART I. ORSHER. M.D., P.C. Patient account # 010224 46010REOfT.CARD E, Patient name JEFFREY EPSTEIN BATE OE EXP!RATI01;; Amount due $ 0.00 tAit NAME:. 5FMMTDRE. X 70:10:5 DATE. . ;DIABNDMSERT: - v EPPREV E0STE!N PstieNtaecounti 01022A Datettehlh! • .C1/22/I953- hs.223. ENCOUNTER P1S 'IMMUKIZATICS GATE PROCEDURE FROM TO LOC (DESCRIPTION OATS1 SERV/GE [Co COOS JHITS AMOUNT r20:E E(ILFSEE CREELS 09/15/17 09/15/17 11 90688 (S) FLUZEIIE OIJACRIVALENT A 95.00 09/15/17 NI (F) AMERICAN EXPRESS 95.00 TOTALS 3 95 00 PHYSICIAN OR PROVIDER pepr.N0. ,PROVIDER 10 NUMBERS En:ART ORSHEP. P.D. IiRNATURE ETTA1=:4' . 14079341z5T EIWNSE It NO. PROV XP-; 13L8A42593 09/15/2017 127681 PATIENT REFERREBBYTW;L:5:"i', $."T'": TAXI)N0. BALANCE PRIOR TO 09/15/2317 $ 0.00 CHARGES 09/15/2017.09/15/20171 STUART CRSHER. M.O. , P.S. 95.00 CREDITS S NINE EAST SEVES.TY-BIM;-i STREET NEW YORK. NY 10075-0123 95.00 PLEASE PAY THIS AAROUAT > 4.18 mmownem.meoNvolvoodaftwamwonar ion's, REG Aire EFTA00299760