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Fax Server 8/6/2014 2:17:38 PM PAGE 1/002 Fax Server UnitedHealth Group FACSI NI I LE T14 ANSNI rITAL SHEET TO: Attn: Jeffrey Epstein FROM: United Healthcare COMPANY: PHONE: FAX: FAX: PHONE: DATE: Wednesday, August 06, 2014 PAGES: 02 COMMENTS: Information included in this document is considered to be UnitedHealthCare's confidential and'or proprietary business information. Consequently, this information may be used only by the person or entity to which it is addressed by Unitedtlealthcare. Such recipient shall be liable for using and protecting UnitedFlealthcare's proprietary business information from further disclosure or misuse. consistent with recipient's contractual obligations under any applicable administrative services agreement, group policy contra. non-disclosure agreement or other applicable contract or law. The report you have received tray contain protected health information 1PHU and must be handled according to applicable state and federal law, including• but not limited to HIPAA. Individuals who misuse information any be subject to both civil and criminal penalties. EFTA00283887 Fax Server 8/6/2014 2:17:38 PM PAGE 2/002 Fax Server UnitedHealthcare Insurance Company Initectifeakheare JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802 Patient: Ref St: Member. • •••••• .• Member ID: Group: Group 0: Letter ID: Qt. C••••<: We received your request for verification of coverage. The following members have coverage under the health benefit plan listed above: Member Name Coverage Effective Date u..:r, • H. v.. • • ,..:::„ Health care services for emergency medical treatment only are covered outside the United States. The services must meet clinical guidelines for a non-work related illness or injury. Please note that payment is based on the submitted claim and the actual health care services received, the guidelines and policies in place at the time of service, and plan and eligibility when the services are received. The information in this letter does not guarantee payment or represent a treatment decision. Treatment decisions are made between you and your physician. If you reach the plan's limit for visits. days or dollar amounts before or while receiving any or all of the services listed in this letter. coverage will not be provided for services above the plan's limit, unless your plan states otherwise. If you have questions about this letter or other questions related to your health insurance, please call the toll-free member phone number listed on your health plan ID card. Sincerely. UnitedHealthcare Visit to view your claims and Explanation of Benefits statements, look up benefits. update account information, find a physician or facility or team more about healthy living. Registration is easy and gives you access to useful tools and information to help you take charge of your health and health care. EFTA00283888