EFTA01122971.pdf

STATEMENT Thomas J. Ma Telephone: Alvin Grayso [Neale.by we ese entree sewnpsi we Perron* ICI ST PS II au Weft Ma011:111. We Neu New York NY 10019 cede Exp Dele Swan Sag Cods Mr. Jeff Epstein Date Account 9 East 71st Street 1/7/2015 9648 New York NY 10021 Remittance PAPORTANT • PLEASE DETACH UPPER PORTIONNCRETURN VRIH YOVR READTTAKE TO PUPAE CREDO TOPROPERA=0a" Date Patient Description Charges Credits Balance 11/26/2014 Previous Balance 0.00 12/17/2014 350.00 350.00 12/17/2014 40.00 390.00 12/17/2014 180.00 570.00 12/17/2014 65.00 635.00 Account Total 636.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete top part of this statement, or call the office at Current 30 Days L 80 Days 90 Days 120+ Days 635.00 0.00 0.00 0.00 0.00 Thomas I Magnanis Mal GleySon EFTA01122971  HISTORICAL STATEMENT 17J1/2014 to 3/3/2015 Thomas J. Ma . Telephone: Alvin Gra son Mr. Jeff Epstein Date Asxsilt 9 East 71st Street 3/3/2015 9648 New York NY 10021 NoTnnolCO liTITOATATTY•fteASIT CANACN WPM venomNO RETURN MTh YOUR lo UMACC TO AMU CRONY YOOROM ACCOUNT Date Patent Description Charges Credits Balance 6/20/2014 Previous Balance 0.00 12/17/2014 350.00 350.00 12/17/2014 40.00 390.00 12/17/2014 180.00 570.00 12/17/2014 65.00 635.00 1/8/2015 0,00 635.00 1/8/2015 7,500.00 8,135.00 1/30/2015 635.00 7,500.00 2/9/2015 25.00 7,525.00 Acccirunt Total 7,526.00 Patient Charges 6.160.00 Patient Payments 636.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may compel le P Part of this statement, or call the office 6:11.1iiiii ° Current 26.00 30 Days 7,600.00 J 60 Days 0,00 90 Days 0.00 129.- Days 0.00 Thames J. Magnanlilli Atiiin Grayson D.O.S. EFTA01122972  STATEMENT Thomas J. Ma . Telephone Alvin Grays IIawn by ay& mod.Mt OM Mont Ku we *MC SISIsmeass Sas NW ■ *A Saw. Naiad Ws Ass Cads Ey Dols Spates S Q CsOs Mr. Jeff Epstein Date Account 9 East 71st Street 6/3/2015 9648 New York NY 10021 Remittance sIPORTN4Y • PLEASE DETACH UPPER PORTON NC RETURNMH YOUR RIEETTNICE TO INSURE CREDIT TO PROPER OCCOSINT Date Patient Description Charges Credits Balance 4/30/2015 • 0.00 5/29/2015 1,100.00 1,100.00 , ( 01,...tcA Account Total 1,100.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 1,100.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl S Alvin Grayson M. EFTA01122973  STATEMENT Thomas J. Ma • TelephoneMill Alvin Gra son PION by PPM cart cm* too OfiCtell you as paying v. to ratailanoi tag arel SPA DEEP Wasisrard Na Penn GOV Earn CME• SQ COS Mr. Jeff Epstein Date Account 9 East 71st Street 10/29/2015 9648 NewYork NY 10021 Renter's IMPORTANT • PLEASE MACH UPPER PORTKINNC RETURN NTH YOUR PRUARTANCI TO MUNE CREDIT TO PROPER Accouter Date Patient Description Charges Credits Balance 9/30/2015 Previous Balance 0.00 10/22/2015 ■ 40.00 40.00 10/22/2015 180.00 220.00 Account Total 220.00 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 220.00 0.00 0.00 0.00 0.00 Thomas J. Magna/M. Alvin Grayson-. EFTA01122974