EFTA00282964.pdf

Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 110%, :Wait 02/05/2015 I 0000008048 1 02/05/2015 1275.00 Paid by Paid By Date Procedure Description Charges Insurance Patient Adj. Balance 01/22/2015 01/222016 01/22/2015 01222015 99205 11100 17000 17003 nit..-.. A n.tne N n. 729 PCS AVM 1611 new. in• 16321 IIIIIIIf New Pt High Complexity Biopsy/Skin, 1st Dest Ben/Premalig 1st Dest Ben/Premal 2-14 herthemt MESS:332443 Try ID: 51,302443 Rirf II: Won Phone Order turoutia pEk Entn NS& !trial Tote: $ 1.21N RittIS 11:13:18 Inv II: ail Pax Code: kali: Online Batch:: Coato.n. Coe, TWIN NW' 500.00 260.00 176.00 350.00 $0.00 $0.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT )NTACT menssalliM EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 02/05/2015 Please remit payment of $0.00 payable to: MITCHELL A Kt I NE, MD PC EFTA00282964 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UN FORM CLAIM COMMITTEE INUCC) OV12 UNITEDHEALTHCARE P 0 BOX 740800 ATLANTA GA 30374 RICA PiCA1 1 1 MEDICARE MEDICAID TRICARE OiNOINA GROUP FECA OTHER HEALTH PLAN BLK LUNG (Mecacive IN 7 (Medcwirl kJ :: (Sponsors SW❑ ( (&SN Or 0) 7 aye El ao, IS. INSUREUM NUMBER (For Program in bin 1) 854905597 • IENT$ NAME (LM Nem Fat Nan. M' Hoe) JEFFREY 3 PATIENTS BATH DATE SEX MM OD w EPSTEIN. 01 I 20 1953 m 15(1 r r 1- 4 INSUREOIS NAME (Lan Plaint FYN NAM. WS AWN) EPSTEIN, JEFFREY S PATIENTS ADDRESS (No. Woe 6 PATIENT RELATIONSHIP TO INSURED 9 EAST 71ST STREET so ril sp.7 ch•40 cm..0 7. INSUREDS ADDRESS (No.. stew 9 EAST 71ST STREET 'Er NEW YORK i STA‘b NY 1 RESERVED FOR (wet tee cat NEW YORK STATE NY ZIP COOE I • 10021 TELEPHONE Creel Mar Cede) ZIP CODE TELEPHONE (Inclueis Area Cone/ 10021 9. OTHER INSUREDS NAME WIN Nene. First Nome. Miele nee le IS PATIENTS CONDITION RELATED TO. I I. INSURED'S POLICY GROUP OR FECA NUMBER 272605 a one, k INS LATEUTIRATCGIRTZERWRIZEI NEC O. EFAINOYMENTI (C,etfl **Prevail,) 0 YES F1 NO TINSOHEUa LIAIT Ur MR M 1MA OD W SEX 01 ; 20 1 1953 ''' X F f'7 0. RESERVED FOR NUCC USE b. AIM ACCIDENT? PUCE MAO O YES 0 NO : ... i b OTHER CLAIM ID Illeenite by NUCC) G. RESERVED FOR NUCC USE e OTHER ACCIDENT? DYES ENO : INSURANCE PLAN NAME OR PROGRAM NAME UNITEDHEALTHCARE 1 INSURNeCE PLAN wee OrPROCRAM NAME Nia CLAM CODES Ltarnemerby NUC I o IS THERE ANOTHER WEALTH !ENNIO' KW n YES Lci nCH NO If ye comFAMS Mme R as. and gcl READ BACK OF FORM BE 0 E COMPLETING It PATENTS OR AUTHORIZED PERSONS SIGNATURE I tI.00n2.0 the LO Moen Oa claim I so Nee payment of government bone% Neer 0010" Signature on file SIGNED & SIGN S SIGNING THIS FORM of any rne‘cal or or, Inrdmition necessary lo nee o' a the Party ono IHMOle mormeen 02 05 2015 DATE 11 INSUREDS OR AUTHORIZED PERSON'S SIGNATURE i ou narlE0 WNW 0 misdeal beneall 10 Mu urcielane eyetian Of .whine tor *NYCO COM:rb,10 WON SIGNED i COATE OF eurtimurttuess IN.0 Y• or KEG (LMPI MM OD Yv DUAL. 'QUAL. 15 R DAYS i MM DO I W MM e. OATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DO TY TO M19.1 . DO W FROM IX NAME OF REFERRING PHYSICIAN OR OTHER SOURCE iy, I it HOSINTALUATION PATES RELATED TO CURRENT SERVICES mom MM 00 TO IDA I DD Y.( obi ten I W —. ADVirtni. CLAIM INFORMATION Dosmnineo by h UGC) 20. OUTSIDE La? S CHARGES-4 n YE8 2: N° N sisoR LL R INJURY (Rats Pa. to wince Ina bee (4 41 ) lop imi 19 i 2382 A I__ Et 7020 c. i 0 22.0881/1MISSION I ORIGINAL REF. NO. E F. 1—__ G I H. t--- 23. PREOR AUTHORtATION NUMBER 24 A PATIO) OF SERVICE s From To PLACE OF WA DD TY WI DO rc I SERVICE D. [ D PROCEDURES. SERVICES. OR SuPPLES {5.9lain Unusual Cirortoaroos) ENG , CPTRICPCS I MODIFIER E. mAGNOSIS POINTER F, 3 CHARGES G. O DARYS UNITS H. EPSDT F" Pie, L ID. DUAL .1 RENDERING PROVIDER ID 9 01 22 15 1 01 • 22 15 1 11 N ' 99205 25 A 500. 00 1 NPI 1932136231 01 22 16 I 01 22 16 1 11 I N I 11100 159 I A 1 2501 00 I 1 NPI 1932136231 01 22 151 01 22 15 11 I N 1 1/000 159 ' B l 175' 00 I 1 I NPI 1932136231 01 22 15 1 01 22 16 1 11 1 N I 17003 7 I I B I 350 00 I 7 I NPI 932138211 1 I ) I 1 I I NPII , H I NPI 2... FEDERAL TAX NUMBER SSW EN 21 PATIENTS ACCOUNT NO 133843772 n 31 0000008048 27 ACCEPT ASSIGNMENT? _iraraaan s ()see. se back) LJ 2a TOTAL CHARGE s 1275.00 29 AMOUNT PAID s 1275'00 30 Ftsvd o NUCC Um 31. FO D ETCus=i R SUPPLIER 32 SERWCE FACILITY LOCAL ION ',FORMATION INCLUDING DEGREES OR CREDENTIALS . Mitchell A Kline MD i.oworl, EWE* sleteneffiCS On the MAYO KAY 10 thee be SAE ye meth? e Pen temes.) 70D Park Ave MITCHELL A KLINE MD PC New York NY 10021 33. BILLING PROVIDER WO A PH i 212 517 6555 MITCHELL A KLINE MD PC 700 PARK AVENUE NEW YORK NY 10021 SIGNED O DA 2 s 0 6 5 2015i 41154489318 7 S. .L1154489316 INT OR TYPE APPROVED 0M8-0938-1107 FORM 1500 (02.12) NUCC Insatiate-I manual available at vew nuCterfg EFTA00282965