EFTA00313719.pdf

RECEIVED 08/30/2017 12: 321:$1 2127174672 71st St receipt Please return top portion with your payment addressed to: STUART 1. ORSHER. M.O.. P.C. DIPLOMATE. 90ARD INTEMiN. MED:CINE 9 E 79TN ST NEM TCRit. NY 10075.0:23 Mee *set 212-535.7763 JEFFREY EPS tIN 9 EAST 71ST STREET NEW YORK. NY 10021 Please indicate any wreaths to %mit 14k.... Receipt date C8/30/20I7 STUART I. ORSt€R. M.O.. P.C. Patient account a 010V4 Patient name ;urger EPSTEIN Amount due $ 3.80 68/33/17 ail:/17 08/30/17 08/38/17 08/30/17 08/30/17 08/30/17 08/33/17 08/30/17 08/30/17 00/30/17 38/33/17 08/30/17 08/3C/17 08/30/17 08/30/17 08/30/17 08/30/17 00/30/17 PhYSIC•Att SAID:tilt STUAA 3814En u D /MATURE :1 11 11 11 11 11 11 11 11 99215-2S 93000 94010 60061-91 82948 83036 81000 36415 827/0 AM ;$) PHYSICAL EXAM (S) It/ INTERP (S) KILKMART FUNCTION (S) LIP:0 PVC (S) GLUCOSE SICK TEST (S) GLYCOSYLATED (A1C) (5) LRINALYSIS-CDPLETE (S)vccputioun (S) STOOL GOAIAC (F) NVERICAN DRESS wTE 08/30/2017 7:-LART CASPIER. M.D.. P.C. EAST SEVENTY-NINTH STREET KEA- vORK. NY 1CC75.O:23 e lmormOnsOmmlAmmemartios -1-vewocv.Tsw.Sr2MY Receipt date 18/30.'20:' Patient account if Patient name Amount due Amount en:lined •r a tetiriunes.. nl'a•• au' - • g rztr..-7:. .riNualiiti;Er.ri".- 8973:433:4.• - • - `u- rnein*.mmtim. . . 1.. • • y: "Oa VETT- rARD •7 7• — :114qc t r t44: s'.'‘'Lli7-LAC 7 DA7T. - Diagnosisfor. ;EF".EY rDSTEll Patientsecougt# 0:(224 .....--... -‘ Dateotairttc 1•CCT?P•21-- 9 :12 '4.•7.ttr 4:4 '493c41* 7-,;74.P: ,ht ],-;A:c Ailk:Z.7,,_ 75-.11DA.. C'ES13•}... S(Y; 7ASS OATS' SERVICE I I ANO 4.8.0 B B C C C A.8.8 A.B.0 ALS no IO NUMBERS co. rpI AcIENTREFERR RY • _ 845.00 136.00 135.00 Ils.00 x5.00 95.00 40.00 45.00 18.00 1490.00 RALANCEPRIORTO 0e/ /8011 0 0.00 CHAPGES 08/30/2017.08/30/2017$ 1.490.00 CREWS $ 1.490.00 - EFTA00313719