EFTA00316467.pdf

MAKE CHECKS PAYABLE TO IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS. FILL OUT BELOW CHECK CARD USING FOR PAYMENT Peter Rubin M.D., P.C. lil 0 0 • MASTERCARD DISCOVER VISA AMERICAN EXPRESS 920 Park Ave CARD NUMBER AMOUNT 1N New York, NY 10028-0208 SIGNATURE EXP. DATE STATEMENT DATE PAY THIS AMOUNT ACCOUNT NUMBER ADDRESS SERVICE REQUESTED 12/01/2018 1,100.00 5855 SHOW AMOUNT PAGE NO. 1 PAID HERE $ ADDRESSEE REMIT TO Jeffrey Epstein Peter Rubin M.D., P.C. 9 East 71 Str 920 Park Ave Ny, NY 10021 1N New York, NY 10028-0208 O None Gook too ff aboto onicoss cs wowed or Ammo ild0rMatiCal ha, dhatidad, and iataCata CIMINES) on towns WO STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Date Ins. Diag. Patient Date Billed Code Dr Description Charge Ins. Pmt. Pat. Pmt. Adjust. Balance 07/30/18 Jeffrey 43239 PHR Egd Wlbiopsy R07.9 1,100.00 0.00 0.00 0.00 1,100.00 Current 31 - 60 Days 61 - 90 Days 91 - 120 Days Over 120 Days Total Balance Ins. Pending Patient Due 0.00 0.00 0.00 1,100.00 1,100.00 0.00 1,100.00 Doctor Codes PHR Peter H Rubin, MD Make Checks Payable To: Peter Rubin M.D., P.C. 920 Park Ave 1N New York, NY 10028-0208 " Balance is overdue. Contact us or be referred to a collection agency. ** EFTA00316467