EFTA00317358.pdf

..• Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY "0021 • WistPic:- ' . -44.146eopLats,AmiTaft); 04/08/2015 1 Last Payment JEFFREY EPSTEIN 9 EAST 71ST STREET Date ' Amount NEW YORK, NY 10021 04/08/2015 675.00 Paid by Paid By Description Charges Insurance Patient Adj. Balance Date Procedure 04/08/2015 99214 Est Pt Visit Detailed 500.00 500.00 04/08/2015 17000 Dest I3en/Premalig 1st 175.00 175.00 7E0 PPFel Atit£ C NY 10321 1193746 1133746 Ref I: 0311. I - . .... ID 6D IItC~lID, T Sale awumill WEI EntrY IS: SiiiPed Total: $ 615.93 &4&4S 18:29:45 Inv t.: VW pear Code: - A;P:Nd: 0rloe Satc.4: " 30• 9'O Pays. 91. '1:120 Days > 120 Days Ratite • Curren, ,ast. [Mel 'poii6ue Past Due ::*.kylri• $0.00 T $0.00 $0.00 $0.00 $0.00 $0.00 CUT ON DOTTED UNE AND SEND WITH PAYMENT Notes: FOR BILLING INQUIRIES CONTACT Statement Date: 04/08/2015 POR YOUR RECORDS Please remit payment of $0.00 payable to: MITCHELL A KLINE, MD PC EFTA00317358