EFTA01118658.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street mind by wend cord. *Mos Me amount sou ors psyes In Spe mew Ws and fi WI below. 7th Floor Mostertard Visa Sewn New York NY 10019 Cade Elm DIM Scrotum SSI COOS Mr. Jeff Epstein Date Account 301 East 66th Street 4/4/2012 9648 Apt 1OF Remittance New York NY 10065 IMPORTANT PLEASE DETACH UPPER PORTION MD RETURN WITH YOUR REMITTANCE TO /NSURE CREDIT 70 PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/1/2012 Previous Balance 0.00 4/3/2012 40.00 40.00 4/3/2012 180.00 220.00 4/3/2012 65.00 285.00 Account Total 285.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the top part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 285.00 0.00 0.00 t 0.00 0.00 Thomas J Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA01118658