EFTA00304839.pdf

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