EFTA00314241.pdf

New Rx from PPI t. JEFFREY EPSTEIN C5*- -' 12-6 (2CiS— DOB: 0112011953 9 EAST 71ST STREET Ph: Sex: M NEW YORK, NY 10021 Written: Absorica 20 mg capsule Written,. 01/1 5/2 019 Qty3Q Capsule Refills: 0 Days Supply: DAW: 1 Substitution Not Allowed by Prescriber. Qd Notes from Prescriber: Mitchell Kline MD 700 Park Avenue New York, NY 10021 NPI: 1932138231 DEANumber: BK0650831 Electronically Signed By (SP0: 6755230500004 Diagnosis Code: Eloctrod=alb• Troosm hod To: NCPDP: 570q`'n4 Publix N1395 Palm Beach Phone: 135 IPadloy PI Signed Date: 01/1512019 Palm Eoach. rL a)dacce19 Prescriber Order U: 11180476 Time 02:41:03 Eastern Standard EFTA00314241 Ede 8ctMlies fools Rs Queues fiearch yelp t• 4 11 0 • "1 - ai - Current ken 1 oi1 ea Cyder Number A3132179 . Fa 00 Nerd 884kflow Stec" enspill tr . (I) I 7114. . 17 JEFFREY EPSTEIN MITCHELL A KLINE Written IF 7l: ABSORICA 20 MG CAPSULE Plan UNITE1) HEALTHCARE - 358 EL BRILLO WAY 7O0 PARKAVE Dispensed irer ABSORICA 20 MG C Code UHCIN NDC s 10631.0116.69 PALM BEACH, FL 33480 Group Number UHC 10021 Pack Size 10 BIN Number Male Avail IF9l 00 PCN NPI 1932136231 0151 RANBAXY/SUN PHA Contact Number (F41 None Pharmacy UPI DEA BK065O831 Rx Humber: 6191993.1395 Date of Sennce 01115/2019 .. _ . Tx Member: 0000471266 Claim Type. 81 - Ming Claim Status. Regatta' Authorization Number. 1901549913413232999 Claim Format D.0 SXC COMMERCIAL CLAIM FORMAT Cardholder ID 854905597 Quantity Dispensed 30 Times Submilled 5 Store Number 1395 Help Desk Number OwS SuPoly. 30 Reed Codes Response Messages L Third Party OUR 70 - Product/See/ice Not Coerced -PI WIREDHEALTHCARE .COMMERCIAL AdjudicationRaja, i Response Message Adelional Message Information Use branded genencs for Accutane Plan Exclusion I Load DUR History into DUR Delals Histopcal DUR I Inventory is NO1 resolved for this Its. Manage Claims ® I I Process as Cash 0 I 0 Qancel Item Order Details I Additional information I Claim Detail 124 Image I Print Rejection Auto Resubmit13 8 I N813,1 Decline SIgpi Close 1K ■ I I .01 Marla Saach rons1395 +stet na -17•1171" a etralgorafivi a • • EFTA00314242