EFTA00282964.pdf

Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 110%,:Wait 02/05/2015 I 0000008048 1 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 1275.00 02/05/2015 Paid by Paid By Description Charges Insurance Patient Adj. Balance Date Procedure 01/22/2015 99205 New Pt High Complexity 500.00 01/222016 11100 Biopsy/Skin, 1st 260.00 01/22/2015 17000 Dest Ben/Premalig 1st 176.00 01222015 17003 Dest Ben/Premal 2-14 350.00 nit..-.. A n.tne N n. 729 PCS AVM 1611 new. in• 16321 IIIIIIIf herthemt MESS:332443 Try ID: 51,302443 Rirf II: Won Phone Order turoutia pEk Entn NS& !trial Tote: $ 1.21N RittIS 11:13:18 Inv II: ail Pax Code: kali: Online Batch:: $0.00 $0.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT Coato.n. Coe, EPSTEIN, JEFFREY TWIN NW' ACCOUNT NO. )NTACT menssalliM 0000008048 Statement Date: 02/05/2015 Please remit payment of $0.00 payable to: MITCHELL A Kt I NE, MD PC EFTA00282964  UNITEDHEALTHCARE 1500 P 0 BOX 740800 ATLANTA GA 30374 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNFORM CLAIM COMMITTEE INUCC) OV12 RICA PiCA1 1 1 MEDICARE MEDICAID TRICARE OiNOINA GROUP FECA OTHER IS. INSUREUM NUMBER (For Program in bin 1) (Mecacive IN 7 (Medcwirl kJ :: (Sponsors SW❑ ( HEALTH PLAN (&SN Or 0) 7 BLK LUNG aye El ao, 854905597 • IENT$ NAME (LM Nem Fat Nan. M' Hoe) 3 PATIENTS BATH DATE SEX 4 INSUREOIS NAME (Lan Plaint FYN NAM. WS AWN) MM OD w EPSTEIN. JEFFREY 01 I 20 EPSTEIN, JEFFREY 1 953 m 15(1 r r 1- S PATIENTS ADDRESS (No. Woe 6 PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No.. stew 9 EAST 71ST STREET so ril sp.7 ch•40 cm..0 9 EAST 71ST STREET 'Er i STA‘b 1 RESERVED FOR (wet tee cat STATE NEW YORK NY NEW YORK NY ZIP COOE I• TELEPHONE Creel Mar Cede) ZIP CODE TELEPHONE (Inclueis Area Cone/ 10021 10021 9. OTHER INSUREDS NAME WIN Nene. First Nome. Miele nee le IS PATIENTS CONDITION RELATED TO. I I. INSURED'S POLICY GROUP OR FECA NUMBER 272605 a one,k INS LATEUTIRATCGIRTZERWRIZEI NEC O. EFAINOYMENTI (C,etfl **Prevail,) TINSOHEUa LIAIT Ur MR M 1MA OD W SEX 0 YES F1NO ''' X F f'7 01 ; 20 1 1953 0. RESERVED FOR NUCC USE b. AIM ACCIDENT? PUCE MAO b OTHER CLAIM ID Illeenite by NUCC) O YES 0 NO : ... i G. RESERVED FOR NUCC USE e OTHER ACCIDENT? : INSURANCE PLAN NAME OR PROGRAM NAME DYES ENO UNITEDHEALTHCARE 1 INSURNeCE PLAN wee OrPROCRAM NAME Nia CLAM CODES Ltarnemerby NUC I o IS THERE ANOTHER WEALTH !ENNIO' KW n YES Lci nCH NO If ye comFAMS Mme R as. and gcl READ BACK OF FORM BE 0 E COMPLETING & SIGNING THIS FORM S SIGN 11 INSUREDS OR AUTHORIZED PERSON'S SIGNATURE i ou narlE0 It PATENTS OR AUTHORIZED PERSONS SIGNATURE I tI.00n2.0 the of any rne‘cal or or,Inrdmition necessary WNW 0 misdeal beneall 10 Mu urcielane eyetian Of .whine tor LO Moen Oa claim I so Nee payment of government bone% Neer lo nee o' a the Party ono IHMOle mormeen *NYCO COM:rb,10 WON 0010" Signature on file DATE 02 05 2015 SIGNED SIGNED i COATE OF eurtimurttuess IN.0 Y• or KEG (LMPI 15 R DAYS e. OATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM OD Yv MM DO I W MM DO TY TO M1 9.1 . DO W DUAL. 'QUAL. i FROM IX NAME OF REFERRING PHYSICIAN OR OTHER SOURCE I iy, it HOSINTALUATION PATES RELATED TO CURRENT SERVICES I mom MM 00 W obi ten TO IDA I DD Y.( —. ADVirtni. CLAIM INFORMATION Dosmnineo by hUGC) 20. OUTSIDE La? S CHARGES-4 n YE8 2: N° N sisoR LL R INJURY (Rats Pa. to wince Ina bee (441 ) lop imi 19 i 22.0881/1MISSION I ORIGINAL REF. NO. 2382 A I__ Et 7020 c. i 0 E F. 1—__ GI H. t--- 23. PREOR AUTHORtATION NUMBER 24 A PATIO) OF SERVICE s D. [ D PROCEDURES. SERVICES. OR SuPPLES E. F, G. H. L .1 From To PLACE OF {5.9lain Unusual Cirortoaroos) mAGNOSIS OYS F" DAR EPSDT ID. RENDERING WA DD TY WI DO rc I SERVICE ENG , CPTRICPCS I MODIFIER POINTER 3 CHARGES UNITS Pie, DUAL PROVIDER ID 9 01 22 15 1 01 • 22 15 1 11 N ' 99205 25 A 500. 00 1 NPI 1932136231 01 22 16 I 01 22 16 1 11 I N I 11100 159 I A 1 2501 00 I 1 NPI 1932136231 01 22 151 01 22 15 11 I N 1 1/000 159 ' B l 175' 00 I 1 I NPI 1932136231 01 22 15 1 01 22 16 1 11 1 N I 17003 7 I IB I 350 00 I 7 I NPI 932138211 1 I NPII ) I I I 1 H , I NPI 2... FEDERAL TAX NUMBER SSW EN 21PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT? 2a TOTAL CHARGE 29 AMOUNT PAID 30 Ftsvd o NUCC Um 133843772 n31 0000008048 _irara aan LJ s ()see. se back) s 1275.00 s 1275'00 31. FO D ETCus=i R SUPPLIER 32 SERWCE FACILITY LOCAL ION ',FORMATION 33. BILLING PROVIDER WO A PH i 212 517 6555 INCLUDING DEGREES OR CREDENTIALS . Mitchell A Kline MD i.oworl, EWE* sleteneffiCS On the MAYO MITCHELL A KLINE MD PC KAY 10 thee be SAE ye meth? e Pen temes.) 70D Park Ave 700 PARK AVENUE MITCHELL A KLINE MD PC New York NY 10021 NEW YORK NY 10021 SIGNED O2 0 5 DAs6 2015i 41154489318 7 S. .L1154489316 NUCC Insatiate-I manual available at vew nuCterfg INT OR TYPE APPROVED 0M8-0938-1107 FORM 1500 (02.12) EFTA00282965