EFTA00313283.pdf

a Mount Faculty Practice Sinai Doctors CARDIOVASCULAR INSTITUTE OF MO P.O. BOX 28083 NEW YORK NY 10087-8083 FOR BILLING INQUIRIES: "P dfill09HOIN90"0"1410"09P41440I JEFFREY EPSTEIN rig 9 E 71ST ST NEW YORK NY 10021-4102 n Pease chef,. box n above address is moat I ce Nsufance in:a:nate, Has (Paned. ale Mlute cTsJgHs1 on teverSt sbe IF PRISM Elf VISA. ILLSNACARIX MOOSE. OR NAZIOCAll EXPRESS. FILL OUT BELOW OMR DE Denman amsoavEn CIN . EIMER EXP.1. TO reC lama IICMAVL•it ▪ PC1J.011 • OMR SOCLAIT, OM. MOM 0.1010, WIC STATEMENT DATE PAY THIS AMOUNT ACCOUNT NO. 11/01/13 CHAROESANDCREDITS LUDEACTERSTATE1 ESTriTIOW AMOUNT simmuAPPEAROmifenswEvor PAID HERE L MAKE CHECKS PAYABLE / REMIT TO: $55.00 1023)$ . 112 STATEMENT 26-3354934 CARDIOVASCULAR INSTITUTE OF MO P.O. BOX 28083 NEW YORK NY 10087-8083 PLEASE DETACH MD RETLAN OP PORTION MTH YOUll PAYMENT IN ENCI OSLO EliVELOFE DATE OF SERVICE • DESCRIPTION OF SERVICE AMOUNT 1 0/24/13 1 AD 110122266 900.00 10/24/13 1 09967 PHARMACEUTICALS 55.00 10/25/13 TOS CREDIT CARD PAYMENT -900.00 • PLACE OF SERVICE 1 DOCTOR'S OFFICE 4 SURGI-CENTER 2 HOSPITAL 5 OTHER 3 EMER. ROOM Date Patient Name Account No 11/01/13 JEFFREY EPSTEIN 26-3354S34 PAYMENTS RECEIVED AFTER THIS DATE APPEAR ON YOUR NEXT STATEMENT. THIS AMOUNT IS DUE 555.00 Make check payable to: CARDIOVASCULAR INSTITUTE OF MO Poi all billing questions. call: 212-9874100 **PAY YOUR BILL ONLINE** Your prompt payment Is appreciated. If you hove provided us with Insurance information,' You can now review your account details and pay your bills deem VMS oho ant to your cry. la the svent thal Payment fcg your cage la maned online' whenever it is convenient for you. to you, please fonverd the payment to us In the endued envelope. Thank you. You may also Login to httpsINAArw.mountsinalorg/mymountsinat and contact us by email at DOMCSSMOUNTSINALORG register. Once the account has been created, you can pay your bill using our new MyMountSinai Patient Online portal. STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 102330-112 EFTA00313283 IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... PATIENT INFORMATION INSURANCE INFORMATION Your Name Oast FkM, MiidM Weal) Dote el Earth VOW PRIMARY Insurance COmPann Ten Addams Teleilaine — Social Security Employers Name EMPloYer's Address City Rene indcate it Appbosbit C AUTO ACCIDENT WORKERS COMPENSATION State Slate Telephone Date of Injury P*, Insurance Company's Address City State Ip Policyholder Name Dated Sinn Sea Pcicytoldses ID Minter' dap Plan Numb; Vat SECONDARY Insurance Company% Herne &cagey Insurance CompanYesiddresa Policyholder Name Sale Date of SIM _ . PaCyhOderk q Number Group Plan Number "DETACH HERE AND RETURN ABOVE STUB" FOR HOSPITAL OR OTHER FACILITY PATIENTS YOU COULD RECEIVE TWO OR MORE BILLS FOR SERVICES PROVIDED TOTAL DIAGNOSTIC OR TREATMENT COSTS PHYSICIAN OR PROVIDER'S FEE HOSPITAL CHARGES OR OTHER FACILITY This statement is not a duplicate charge, but a separation of the facility and physician or provider's fees. These services were provided while you were under our care, or at the request of your other physicians or providers. Your bill from the facility may include a separate charge for use of its equipment, supplies, and technical personnel. You may also receive bills from other physicians or providers who were involved with your care if you were a patient in a hospital or other facility. If you have any questions concerning your bill, please call our office and we will be happy to assist you. IF YOU REQUIRE ASSISTANCE, YOU MAY CONTACT OUR OFFICE AT THE PHONE NUMBER ON THE REVERSE SIDE. PAP.201 CO EFTA00313284