EFTA00312711.pdf

afivik Quest tai Diagnostic.: CAC= Me 5750 I1 Kik THR I!9782381 JEFFREY EPSTEIN 9 E 71 ST NEW YORK. NY 10021.4102 I...1111,..11..,n1.1,..11.14.1...1111.....1.111,..1.1,.11...I Laboratory Tests Were Requested By: Referring Physician. WOODSON MERRELL. Physician Address 44 E.67TH STREET NEW YORK NY 11Y195 Laboratory Invoice For seines not incanted n your pin cans be Page 1 Invoice Number Lab Code 119782384 TBR Customer Service LOG ON NOW at to conveniently pay your invoice, provide updated insurance information. or take a patient survey. Phone Fax 1.800-631-1388 Weekdays 8.30AM 5 PM EST Se Hebb Espanol Please have your invoice available for reference. Most Recent Insurance Claim Filed To: Insurance Name. Insurance ID Group Number: Lab Results and Diagnosis Questions Must Be Answered By Your Physician vattent Name. JEFFREY EPSTEIN Responsible Party: JEFFREY EPSTEIN Date of Service: February 11, 2011 Invoice Date. February 15.2011 Amount Due. $220.00 Payment Due Dale 03/1212011 These tests were ordered by the relearn° physician. Mu) requested that we bill you directly. II you have insurance coverage for the Service dale, please contact us to provide your policy information If payment is not received by the duo dale and we locale insurance information we will submit a claim for payment. Thank you for using Quest Diagnostics. CPT Dar Cake: 0211 1111 Oratil otrisni Myr senctocii. SEttratOGY Tett Do:venation Charge 611000 511000 Insurance ascot * Insurance pa4 Medicare/ , Patent Medicaid Paid 1_ Pad Patent Own Tax ID: 18-13,378.2 IC0-9 Cocks: 597 80 ScontsPataroalby QUEST DinCAINAS TETERBORO 41% Quest Diagnostics Payment Coupon LOG ON NOW. Pay your bill online securely anytime - day a night at or call 1.800.631-1388 Quest Diagnostics also accepts $220.10 WOO $0.00 $0.00 t0.00 $22000 'Toe CPT codes prowled are bastion AMA "addaxes aM valhcoi regard nponlic paw, I eily",11"," • Please fold and tear payment coupon along peas:anon and rand with payment n the envelope provided • • yi VISA MatterOfd Please make your check payable to Quest Diagnostics Be sure to include invoice number al your check O Check here if address has changed. Please provide your new address information on the back Oa" Clill":"CSIcben" the ezIrt neeriene In an ""all"." Lab Code TIM Amount Due $220.00 Due Date: 03/12/201i Invoice Number: 119782384 Patient Name JEFFREY EPSTEIN Amount Enclosed: you IttelVtli an anplanaben ci brains shOwag your rosponvibilty is less par the lliTOUte !town on ten bill, (405543 say the eases iterfOteM To Nay ie,ohe )01A Pease panne a cow of rat inettnalien ef benefit,' MAIL PAYMENTS ONLY TO: QUEST DIAGNOSTICS INCORPORATED PO BOX 71304 PHILADELPHIA PA 19176-1304 01TBR15010119782384000220004021501002126441960000009 EFTA00312711 "eh Quest -4 DiagnaitiC1 THIS IS NOT A BILL Dear Patient, We did not receive insurance information to file a claim on your behalf for laboratory tests we performed on the date of service indicated on your invoice. Kindly provide the information requested below so that we may submit a claim to your insurance carrier for payment. Please return this information to us in the enclosed envelope within 10 days. If possible, please attach a copy of the front and back of your insurance card. INVOICE: NAME OF INSURANCE: NAME OF POLICYHOLDER: INSURANCE ID #: GROUP #: RELATIONSHIP TO POLICYHOLDER: POLICYHOLDER S.S. #: PATIENT GENDER: MALE FEMALE PATIENT'S DATE OF BIRTH: POLICYHOLDER DAYTIME PHONE #: We appreciate your attention to this matter. If you chose you may fax it to (484) 676-8788. If payment is required, please remit your payment and the payment coupon in the envelope provided. You can also visit www.questdiagnostics.comibill and submit the information or make a payment. Thank you for using Quest Diagnostics. We look forward to serving you in the future. Sincerely, Patient Billing Customer Service QDX2O3I 06203 062000 EFTA00312712