EFTA00317364.pdf

DAD, PC PATIENT NAME PATIENT DUE BALANCE 108 590.001 59C.00 FOR BILLING INQUIRIES: PAGE:1 of 1 AGING AMOUNTS. 0-30: 0.00 IIIIIrhIIIIIIIIIIrIIhhIIllllllrlllPiIIIIilh 31-60: 590.00 JEFFREY EPSTEIN 61-90: 0.00 301 EAST 66TH ST APT 11P OVER 90: 0.00 NEW YORK NY 10065-6217 228951D5OUTV000024.5 'minium um] DATE TRANSACTION PATIENT NAME AMOUNT Previous Balance: 590.00 LorMr:fin LUBLIAtithillth al farSflhI h If PAYING SY MASTERCARD, DISCOVER VISA OR AMERICAN EMPRESS, RLL OUT BELOW. PA I NT NAME PAT. A DUE PAID CHECK CARD WINS FOR PAYMENT 590.00 = MASTERCARD' = DISCCMER = VISA = AMERICAN EMPRESS CARO NUMBER SIGNATURE CODE SIGNATURE EXP. DATE STATEMENT DATE PAY THIS AMOUNT ACCT. // 6/1/2015 $590.00 Epstein, Jeffrey Incorrect or Q Please chock box if your address Is has changed, and indicate change(s) on reverse she. 328e6 PAGE: 1 of 1 SHOW AMOUNT PAID HERE 1551555 001125 0101 JEFFREY EPSTEIN MARC S. LEMCHEN, D.M.D., P.C. 301 EAST 66TH ST APT 11P NEW YORK, NY 1CO65-621 NEW YORK, NY 100654108 Iniumemummmenini 328051050LHFVOXI2245 EFTA00317364  PLEASE PROVIDE YOUR UPDATED INFORMATION SKINMEDICAL RESEARCH AND DIAGNOSTICS, PL o eL) D E,7j• O VISA U CHECK DOBBS FERRY, NY 105223520 AUTHORIZATION CODE CARD/CHECK NUMBER: 34572 F-1177 TEMP RETURN SERVICE REQUESTED SIGNATURE: EXP. DATE: STATEMENT DATE: 04/29/2015 PAID AMOUNT': $ DUE AMOUNT: 280.00 009672 ACCOUNT NUMBER: For payments through credit card, full balance stud: be charged 6=16 MC I 0101 PATIENT NAME: unless an amount Is provkled. GUARANTOR NAME: PAYMENT DUE DATE: 05/20/2015 ADDRESSEE REMIT THIS PAYMENT STUB TO SKINMEDICAL RESEARCH AND DIAGNOSTICS, PL 301 E. 66TH STREET NEW YORK, NY 10065-6205 NY 10522-0042 (JCheck this box If your address or Insurance Information has changed. Detach and return this portion with your payment. F Indicate change(s) an the reverse of Nis page. Please retain bottom portion for your records. Date of CPT 0P:ciiplIon Amount Pri Ins Sec Ins Other Ins Adjustment Patient Patient Service Code Charged Payment Payment Payment Payment Balance Previous Outstanding balance Mending Physician: MELISSA .GILL 04120/2015 TISSUE EXAM BY PATHOLOGIST 140.00 Primary Ins Rejection Secondary Ira Rejection Other Ins Rejection Totes for this Claim 140.00 0.00 0.00 0.00 0.00 0.0C 140.00 Total Amount Due 280.00 Total Amount Due: $280.00 PATIENT RESPONSIBILITY/REJECTION(S) NUMBER OF DAYS PAST DUE SP - Self pay 81-90 91-120 1 120+ 280.00 0.00 0.00 0.00 I 0.00 Receive Email Statements Register Today! O a CONTACT US: tn. 6..o. 4, t. FOR BILLING INQUIRY, PLEASE CALL AT (8:00 AM - 4:00 PM EST) VISIT: EFTA00317365 fik Mount Faculty Practice ACCOUNT NUMBER PHYSICIAN SERVICES STATEMF.NT DATE Sinai 02/02/15 Doctors Service Description Payments/ Loc. AcljusimentS • OFFICE VISiT - LE E 3 TOTAL BALANCE AMOUNT 300.00 • .. : )V:ii SO Lit)* ^ r • YOU CAN PAY YOUR BILL ONLINE TODAY! SEE PAYMENT PAYMENT OPTIONS OPTIONS Pay online at I MMIIMIM and register. Once the account has been I created, you can pay your bill using our new MyMountSInal Patient Online portal. Pay-by-phon Hours of Operation: 9:00AM TO 5:00PM MON-FRI 2 Malt In a check payable to SURGICAL ASSOCIATES with the section below. _ _ _ •_ — . - Please detach lower portion end send payment In enclosed envelope. if paykig by Cala Cud please NI and below. l—1 O 0 a• D.MEr - Mount Faculty Practice CARD NUMBER cw 0005 MOOED* Sinai SURGICAL ASSOCIATES 2r. Doctors EDICAL CTR SIGNATURE r tesnosiatower NEW YORKNY loon-area RETURN SERVICE REQUESTED D;;E SATri CCOU NUMBEti \ PAY THIS AMOUNT Receipt \ $300.00 Total Amount Paid Here II> $ C) PAY ONUNE A MAKE CHECK PAYABLE AND REMIT TO: _ SURGICAL ASSOCIATES EDICAL CTR 11166” . NEW YORK NY 10065-6205 NEW YORK,NY 10087-0668 EFTA00317366  Palm Beach Pathology- Page 1 of 2 KXd Statement Date: Responsible Party: Thank you for choosing Palm Beach Pathology Account Number: for your health care needs. Due Date: Upon Receipt REQUEST FOR PAYMENT Summary of Account Important Message: Total Charges $ 212.52 Insurance Payments $ 0.00 Your account still has an outstanding baLagoe. Please payment immediately Insurance Adjustments $ 0.00 Tlrahl you frít,"O1-~t atforitiÁr)::: .^ 4 Patient Payments $ 0.00 _Account Adjustments 0_00 -Su cuenta refléja-un balance pendienté.-Per:favor-envic;-su-y- - -- AMOUNT YOU OWE $ 212.52 pago para evitar futuras facturas. Apreciarnos su pronta Your prompt payment is appreciatedl Please see the following atencion. paga for transaction details. This statement is for lab tests your physician ordered from. Palm Beach Pathology on your behalf. We are not affillétet Payment, Insurance, & Billing Information with your physician. The balance is your responsibílity. Please make payment in full using a payment method listed Pay by credit card online to the left on the statement. ff you are melete to pay thefulp. tra o f anytime, 7day or night! amt, please contad our National Billing Office at ~.13 to dIscuss payment options. PLEASE DO E v id d Pay by credit card via phonca NOT CALL YOUR PHYSICIAN REGARDING THIS Certifled, safe and secare credit card processing. STATEMENT. . Visit us at wvvw.peryourhealth.com tgsupdate your No insuranoe coverage indicated for the visit showniabovk insurance, address, vlew your accoat, or send a es offce. To contad the billing office, please cal( a 8:30AM-6:00PM EST Mon-Fri Para asistencia en Español liame el numero de arriba. — Please detach and retum bottom stub wlth your check Pay By Mail — Include account number on oheck and correspondence Account Patient pahn Beacsião~ Pathology- N CHARLF.STON, SC 29406 Statement Date Amount Due Due Date Amount Pelei Temp - Retum Service Requested 12/16/14 $ 212.52 Upon Receipt For your protection: Do not lndude the credit card information in the mal(. Make CHECK payable and remit to: o o PAL*9141314044993C3806 ology tívp, 30i E 667H ST APT I18 ia? NEW YORK, NY 10065-6217 EFTA00317367