EFTA00292227.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 Date Procedure Description ingatMli WAregiiiiNOSIN .R. 02/26/2019 0000008048 1 Br trallipaMOVONO attogiagt 08/10/2016 I cg 2ffilf a it, 875.00 Paid by Paid By Charges Insurance Patient Adj. Balance 01/11/2019 99213 Est Pt Visit Expanded 93.41 93.41 01/11/2019 17000 Dest Ben/Premalig 1st 84.24 84.24 01/11/2019 17003 Dest Ben/Premal 2-14 22.23 22.23 kivt i t/9 Oil - . ti •iz Cu 6s4A 0 . e`)C. j 446 ry• dA 6 - . !fey:onto sclikelit 74.1.,Rurarm bi-:jai/001e At.7.,Eirrioa ViiiiSfitia reviewers ilislirs*itiliteAtt,tpi mat tatyr $0.00 $199.88 $0.00 $0.00 $0.00 Notes: CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTAC EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 02/26/2019 Please remit payment of $199.88 payable to: MITCHELL A KLINE, MD PC EFTA00292227 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 Date L Account No. Pa•e# 02/01/2019 0000008048 1 Last Payment Date Amount 08/10/2016 875.00 Date Procedure Description Paid by Charges Insurance Paid By Patient Adj. Balance 01/11/2019 01/11/2019 99212 17000 Established Pt Visit Straightfwrd Dest Ben/Premalig 1st 250 25'.00 250.00 250.00 01/11/2019 17003 Dest Ben/Premal 2-14 50.00 150.00 A Gate- 1,,ni- efruct, ivtt 4 -c c) 0 el 0-- 04- tecil vt v IA) i r L 0 - 30 Days Current $650.00 31 - 60 Days Past Due $0.00 61 - 90 Days Past Due $0.00 91 - 120 Days Past Due $0.00 > 120 Days Past Due $0.00 Notes: Patient Balance Due $650.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 02/01/2019 Please remit payment of $650.00 payable to: VISA MC AMEX Acct.*, Exp. Date Signature EFTA00292228 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 Date Procedure Description T7:Thr 4 :4 4 Atairalel0 02/26/2019 0000008048 1 pipag„. L-Lttisatierste "Ss.. rs. • . L.. • tip' W a 08/10/2016 875.00 Paid by Paid By Charges Insurance Patient Adj. Balance 02/26/2019 99212 Established Pt Visit Straightfwrd 57.27 ....- 9tti )441 14 - ed 40 44,e th2e57.27 02/26/2019 A92705ELECTRODESICCATION 350.00 /,42 d- nA edic-ae 350.00 " 43 4116V1 ka.__m i rr z anti Eintkl . a - pagigy, al." a s- Da jelfa'as Due ..__. nata rrilt: iDa s _ as , . 4 !DOA% . 1,2p 6Dp . „ ?At n,..eaa $407.27 $0.00 $0.00 $0.00 $0.00 Notes: $407.27 CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 02/26/2019 Please remit payment of $407.27 payable to: MITCHELL A KLINE, MD PC EFTA00292229