EFTA00299760.pdf

rindbe return lap pOrtfOn with your payment addressed to: STUART I. ORSHER. M.O.. P.C. OIPLCHATE. BOARD INTERNAL HEOICINE 9 E 79TH ST NEW YORK. NV 10075-0123 Office p1mw 212-535-1763 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Please indicate any corrections to your address. Receipt date Patient account # Patient name Amount due $ 09/15/2017 STUART I. ORSHER. M.D., P.C. 010224 JEFFREY EPSTEIN 0.00 Receipt date Patient accounts Patient name Amount due $ Amount unclosed S 09/15/2017 010224 JEFFREY EPSTEIN 0.00 '=EASE., J4Kb/B11"11"1 RIITATEEKWIWOINVP6fitnF''34'YOUO EIZRE4 svo 627-ow 7...,i,E\TH.:.1 PATSTNT REOLESTED TINE PLEASE REtBIN'TRIS PORTION POR TC-JR TAX RECORDS receipt 46010REOfT.CARD E, BATE OE EXP!RATI01;; tAit NAME:. 5FMMTDRE. X 70:10:5 DATE. . ;DIABNDMSERT: - vEPPREV E0STE!N PstieNtaecounti 01022A Datettehlh! • .C1/22/I953- h s.223. ENCOUNTER P1S 'IMMUKIZATICS FROM GATE TO LOC PROCEDURE COOS (DESCRIPTION OATS1 JHITS SERV/GE AMOUNT [Co r20:E E(ILFSEE 09/15/17 09/15/17 09/15/17 11 90688 NI (S) FLUZEIIE OIJACRIVALENT (F) AMERICAN EXPRESS A 95.00 PHYSICIAN OR PROVIDER E n:ART ORSHEP. P.D. IiRNATURE TOTALS ,PROVIDER 10 NUMBERS PROV XP-; 13L8A42593 pepr.N0. 14079341z5T ETTA1=:4'. It EIWNSE NO. 09/15/2017 127681 TAXI) N0. 3 CREELS 95.00 95 00 PATIENT REFERREBBYTW;L:5:"i', $."T'": STUART CRSHER. M.O. , P.S. NINE EAST SEVES.TY-BIM;-i STREET NEW YORK. NY 10075-0123 mmownem.meoNvolvoodaftwamwonar BALANCE PRIOR TO 09/15/2317 $ CHARGES 09/15/2017.09/15/20171 CREDITS S PLEASE PAY THIS AAROUAT > ion's, REG Aire 0.00 95.00 95.00 4.18 EFTA00299760