EFTA00313719.pdf

RECEIVED 08/30/2017 12: 321:$1 2127174672 71st St Please return top portion with receipt your payment addressed to: 18/30.'20:' Receipt date Patient account if STUART 1. ORSHER. M.O.. P.C. Patient name DIPLOMATE. 90ARD INTEMiN. MED:CINE Amount due 9 E 79TN ST NEM TCRit. NY 10075.0:23 Amount en:lined Mee*set 212-535.7763 JEFFREY EPS tIN 9 EAST 71ST STREET NEW YORK. NY 10021 •ra tetiriunes.. nl'a••au' - • g rztr..-7:. .ri Nual iiti;Er.ri" .- 8973:433:4.• Please indicate any wreaths to %mit 14k.... - `u- rnein*.mmtim. . . - • Receipt date C8/30/20I7 STUART I. ORSt€R. M.O.. P.C. 1.. • • — y: "Oa VETT- rARD •7 7• Patient account a 010V4 Patient name ;urger EPSTEIN tr :114qc t44: Amount due $ 3.80 s'.'‘'Lli7 -LAC 7 DA7T. - Diagnosisfor. ;EF".EY rDSTEll Patientsecougt# 0:(224 .....--... -‘ Dateotairttc 1•CCT?P •21 -- 9 :12 '4.•7.ttr 4:4 '493c41* 7-,;74.P: ,ht ],-;A:c Ailk:Z.7,,_ 75-.11DA.. C'ES13•}... S(Y; 7ASS OATS' SERVICE I I ANO 4.8.0 845.00 68/33/17 ail:/17 :1 99215-2S ;$) PHYSICAL EXAM B 136.00 08/30/17 08/38/17 11 93000 (S) It/ INTERP B 135.00 08/30/17 08/30/17 11 94010 (S) KILKMART FUNCTION Ils.00 C 08/30/17 08/33/17 11 60061-91 (S) LIP:0 PVC x5.00 C 08/30/17 08/30/17 11 82948 (S) GLUCOSE SICK TEST 95.00 C 00/30/17 38/33/17 11 83036 (S) GLYCOSYLATED (A1C) 40.00 A.8.8 08/30/17 08/3C/17 11 81000 (5) LRINALYSIS-CDPLETE A.B.0 45.00 08/30/17 11 36415 (S)vccputioun 08/30/17 18.00 08/30/17 08/30/17 11 827/0 (S) STOOL GOAIAC 1490.00 00/30/17 AM (F) NVERICAN DRESS ALS no IO NUMBERS PhYSIC•Att SAID:tilt co. rpI STUAA 3814En u D /MATURE wTE AcIENTREFERR RY •_ 08/30/2017 RALANCEPRIORTO 0e/ /8011 0 0.00 CHAPGES 08/30/2017.08/30/2017$ 1.490.00 CREWS $ 1.490.00 7:-LART CASPIER. M.D.. P.C. - - vORK. NY 1CC75.O:23 EAST SEVENTY-NINTH STREET KEA lmormOnsOmmlAmmemartios -1-vewocv.Tsw.Sr2MY e EFTA00313719