EFTA00312739.pdf

Structured Healthcare . Management, Inc. meet Mart JEFFREY EPSTEIN STATEMENT DATE 01/09/2012 magic. 1 AMT. ONE MOM ranter 30.00 ACCT NO. 053177 =I= A Ct REOUESTED Office PhoneMM. MAKE CHECK PAYABLE TO: N Y NEUROLOGICAL ASSOCIATES,. ,,,,, Irlitilli 003372 0.5380 AT 0.365 JEFFREY EPSTEIN 9 E 71ST STREET NEW YORK, NY 10021.4102 AMOUNT ENCLOSED: ATTENTION GHI INSUREDS ONLY: AS OF JANUARY 2001, NY NEUROLOGY NO LONGER PARTICIPATES WITH GHI. CALL EON REGARDING YOUR REIMBURSEMENT. YOU MUST PAY THIS BILL. III 11111111 II 11111 IIIIIII Please contact our billing office at 800.3949201 if your address is incorrect or insurance information hes changed. IIIIIIIIIIIII IIIIIIIIII III 11116111 IIIIIIIII III. IIIIIIIIIIIIIIII DETACH HERE AND RETURN THE ABOVE PORTION %ITN YOUR PAYMENT N Y NEUROLOGICAL ASSOCIATES,.. 162 EAST 78TH STREET NEW YORK, NY 10075.0406 PATIENT INNS FON WPAINElleati JEFFREY EPSTEIN ANOMIE MAIM SEAT WANT DAM PAO( isrmila 053177 01/09/2012 1 DATE FROM TO DESCRIPTION DAYS/ UNITS SERVICE AMOUNT CHARGES PAYMENTS BALANCE 12/27/11 12/27/2011 Portion not paid by insurance (FORM A1B45) For Services: 11/21/2011 • 11/21/2011 Coins-330.00 CO-PAY FOR DATE OF SERVICE 11/21/11 IS $30.00 ACCOUNT BALANCE 30.00 30.00 30.00 MESSAGE PROMPT PAYMENT IS REQUESTED: AMOUNT DUE AMOUNT DUE 30.00 STATEMENT OF ACCOUNT + DuctumE Healthr..va Manegornenl. inc. Er ;.cwooT. Nom JerSey 07631 SHAli•T 123110O3372 0001 EFTA00312739