EFTA00304839.pdf

STATEMENT PLEASE MAKE CHECK PAYABLE TO: IF PAYNG BY CREDIT CARD. FILL OUT BELOW SEAN E MCCANCE MD (44 .= = DI LLcarat :r4.# 1155 PARK AVENUE NEW YORK NY 10128-1209 MASTERCARD VISA DISCOVER AM EXPRESS CRLINT CARD NUMBER EXP DATE SIGNATURE CODE For Billing Inquiries MOW ukE ACCT A RESPONSIBLE PARTY: 45281 STATEMENT DATE PAY THIS AMOUNT SHOW ANOINT Pun HERE JEFFERY EPSTEIN 12/31/13 475.00 9 EAST 71ST STREET CHARGES OR PAYMENTS MADE AFTER CLOSING DATE WILL NEW YORK NY 10021 APPEAR ON NEXT STATEMENT. Pagn a E. Please check box if above address N Incorrect or Insurance Information 0 has changed, end Indicate changels) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT MEDICARE ilk1SURANCE :DATE. . DESCRIPTION CHARGES RECEIPTS RECEIPTS RECEIPTS ADJUSTMENT BALANCE.' WS 12/03/13 OFFICE VISIT NEW PAT MOD 500.00 .00 .00 .00 25.00 475.00 Insurance paid you 81.120 OVER .INSURANCE CURRENT 30-60 DAYS .61-10 DAYS DAYS 120 DAYS BALANCE DUE FROM PATIENT 475.00 .00 .00 .00 .00 475.00 .00 • • PAYMENT DUE UPON RECEIPT + THANK YOU ** EFTA00304839