EFTA00313283.pdf

a Mount Faculty Practice IF PRISM Elf VISA. ILLSNACARIX MOOSE. OR NAZIOCAll EXPRESS. FILL OUT BELOW OMR DE Denman amsoavEn CIN TO reC . EIMER EXP.1. lama Sinai Doctors IICMAVL•it ▪ PC1J.011•OMR CARDIOVASCULAR INSTITUTE OF MO SOCLAIT,OM. MOM P.O. BOX 28083 0.1010, WIC NEW YORK NY 10087-8083 STATEMENT DATE PAY THIS AMOUNT ACCOUNT NO. 11/01/13 $55.00 26-3354934 FOR BILLING INQUIRIES: CHAROESANDCREDITS LUDEACTERSTATE1 ESTriTIOW AMOUNT simmuAPPEAROmifenswEvor PAID HERE L MAKE CHECKS PAYABLE / REMIT TO: "P dfill09HOIN90"0"1410"09P41440I 1023)$ . 112 CARDIOVASCULAR INSTITUTE OF MO JEFFREY EPSTEIN P.O. BOX 28083 rig 9 E 71ST ST NEW YORK NY 10021-4102 NEW YORK NY 10087-8083 n Pease chef,. box n above address is moat I ce Nsufance in:a:nate, Has (Paned. ale Mlute cTsJgHs1 on teverSt sbe STATEMENT PLEASE DETACH MD RETLAN OP PORTION MTH YOUll PAYMENT IN ENCI OSLO EliVELOFE DATE OF SERVICE • DESCRIPTION OF SERVICE AMOUNT AD 110122266 10/24/13 1 900.00 10/24/13 1 09967 PHARMACEUTICALS 55.00 10/25/13 TOS CREDIT CARD PAYMENT -900.00 • PLACE OF SERVICE 1 DOCTOR'S OFFICE 4 SURGI-CENTER 2 HOSPITAL 5 OTHER 3 EMER. ROOM Date Patient Name Account No THIS AMOUNT 555.00 11/01/13 JEFFREY EPSTEIN 26-3354S34 IS DUE PAYMENTS RECEIVED AFTER THIS DATE APPEAR ON YOUR NEXT STATEMENT. Make check payable to: CARDIOVASCULAR INSTITUTE OF MO Poi all billing questions. call: 212-9874100 **PAY YOUR BILL ONLINE** Your prompt payment Is appreciated. If you hove provided us with Insurance information,' You can now review your account details and pay your bills deem VMS oho ant to your cry. la the svent thal Payment fcg your cage la maned online' whenever it is convenient for you. to you, please fonverd the payment to us In the endued envelope. Thank you. You may also contact us by email at DOMCSSMOUNTSINALORG Login to httpsINAArw.mountsinalorg/mymountsinat and register. Once the account has been created, you can pay your bill using our new MyMountSinai Patient Online portal. STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 102330-112 EFTA00313283  IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... PATIENT INFORMATION INSURANCE INFORMATION Your Name Oast FkM, MiidM Weal) Dote el Earth VOW PRIMARY Insurance COmPann Ten Addams P*, Insurance Company's Address State City State Ip Teleilaine — Policyholder Name Dated Sinn Sea Social Security Pcicytoldses ID Minter' dap Plan Numb; Employers Name Telephone Vat SECONDARY Insurance Company% Herne EMPloYer's Address &cagey Insurance CompanYesiddresa City Slate Sale Rene indcate it Appbosbit Date of Injury Policyholder Name Date of SIM C AUTO ACCIDENT _ . PaCyhOderk q Number Group Plan Number WORKERS COMPENSATION "DETACH HERE AND RETURN ABOVE STUB" FOR HOSPITAL OR OTHER FACILITY PATIENTS YOU COULD RECEIVE TWO OR MORE BILLS FOR SERVICES PROVIDED TOTAL DIAGNOSTIC OR TREATMENT COSTS PHYSICIAN OR HOSPITAL CHARGES OR PROVIDER'S FEE OTHER FACILITY This statement is not a duplicate charge, but a separation of the facility and physician or provider's fees. These services were provided while you were under our care, or at the request of your other physicians or providers. Your bill from the facility may include a separate charge for use of its equipment, supplies, and technical personnel. You may also receive bills from other physicians or providers who were involved with your care if you were a patient in a hospital or other facility. If you have any questions concerning your bill, please call our office and we will be happy to assist you. IF YOU REQUIRE ASSISTANCE, YOU MAY CONTACT OUR OFFICE AT THE PHONE NUMBER ON THE REVERSE SIDE. PAP.201 CO EFTA00313284