EFTA00312711.pdf

Page 1 afivik Quest Laboratory Invoice For seines not incanted n your pin cans be tai Diagnostic.: Invoice Number Lab Code 119782384 TBR CAC= Me 5750 Customer Service I1Kik THR I!9782381 LOG ON NOW at to conveniently pay JEFFREY EPSTEIN your invoice, provide updated insurance information. or take a patient 9 E 71 ST survey. NEW YORK. NY 10021.4102 Phone Fax 1.800-631-1388 I...1111,..11..,n1.1,..11.14.1...1111.....1.111,..1.1,.11...I Weekdays 8.30AM 5 PM EST Se Hebb Espanol Please have your invoice available for reference. Laboratory Tests Were Requested By: Most Recent Insurance Claim Filed To: Referring Physician. WOODSON MERRELL. Insurance Name. Physician Address 44 E.67TH STREET Insurance ID NEW YORK NY 11Y195 Group Number: Lab Results and Diagnosis Questions Must Be Answered By Your Physician vattent Name. JEFFREY EPSTEIN Invoice Date. February 15.2011 Responsible Party: JEFFREY EPSTEIN Amount Due. $220.00 Date of Service: February 11, 2011 Payment Due Dale 03/1212011 These tests were ordered by the relearn° physician. Mu) requested that we bill you directly. II you have insurance coverage for the Service dale, please contact us to provide your policy information If payment is not received by the duo dale and we locale insurance information we will submit a claim for payment. Thank you for using Quest Diagnostics. CPT Insurance Insurance Medicare/ , Patent Patent Dar Cake: Tett Do:venation Charge ascot * pa4 Medicaid Paid 1_ Pad Own 02111111 Oratil senctocii. 611000 otrisni Myr SEttratOGY 511000 Tax ID: 18-13,378.2 IC0-9 Cocks: 597 80 $220.10 WOO $0.00 $0.00 t0.00 $22000 ScontsPataroalby QUEST DinCAINAS TETERBORO 'Toe CPT codes prowled are bastion AMA "addaxes aM valhcoi regard nponlic paw, Ieily",11"," • Please fold and tear payment coupon along peas:anon and rand with payment n the envelope provided • • yi 41% Quest Lab Code TIM Diagnostics Payment Amount Due $220.00 Coupon LOG ON NOW. Pay your bill online securely anytime - Due Date: 03/12/201i Invoice Number: 119782384 day a night at Patient Name JEFFREY EPSTEIN or call 1.800.631-1388 Quest Diagnostics also accepts Amount Enclosed: you IttelVtli an anplanaben ci brains shOwag your rosponvibilty is less par the lliTOUte !town on ten bill, (405543 say the eases iterfOteM To Nay ie,ohe )01A Pease panne a cow of rat inettnalien ef benefit,' VISA MatterOfd MAIL PAYMENTS ONLY TO: Please make your check payable to Quest Diagnostics QUEST DIAGNOSTICS INCORPORATED Be sure to include invoice number al your check PO BOX 71304 PHILADELPHIA PA 19176-1304 O Check here if address has changed. Please provide your new address information on the back Oa" Clill":"CSIcben" the ezIrt neeriene In an ""all"." 01TBR15010119782384000220004021501002126441960000009 EFTA00312711  THIS IS NOT A BILL "eh Quest -4 DiagnaitiC1 Dear Patient, We did not receive insurance information to file a claim on your behalf for laboratory tests we performed on the date of service indicated on your invoice. Kindly provide the information requested below so that we may submit a claim to your insurance carrier for payment. Please return this information to us in the enclosed envelope within 10 days. If possible, please attach a copy of the front and back of your insurance card. INVOICE: NAME OF INSURANCE: NAME OF POLICYHOLDER: INSURANCE ID #: GROUP #: RELATIONSHIP TO POLICYHOLDER: POLICYHOLDER S.S. #: PATIENT GENDER: MALE FEMALE PATIENT'S DATE OF BIRTH: POLICYHOLDER DAYTIME PHONE #: We appreciate your attention to this matter. If you chose you may fax it to (484) 676-8788. If payment is required, please remit your payment and the payment coupon in the envelope provided. You can also visit www.questdiagnostics.comibill and submit the information or make a payment. Thank you for using Quest Diagnostics. We look forward to serving you in the future. Sincerely, Patient Billing Customer Service QDX2O3I 06203 062000 EFTA00312712