STATEMENT

STATEMENT Thomas J. Ma . Telephone: Jeff Epstein 301 East 66th Street Apt # 10 f New York NY 10065 II paying by credal card. eaten amoral you ate Piaci in the can bile itC Id col Slaw Mastartard 4Ssa Amex Cams by Or Swaim Sq Coda Date Account 12/29/2011 3114 Remittance IMPORTANT- PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/30/2011 12/14/2011 .Jeff 12/14/201 Jeff 12/15/201' Jeff Previous Balance Recall Oral Exam Adult Scale & Prophy Ins Form submitted - Aetna 40.00 180.00 0.00 40.00 220.00 Account Total 220.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete top part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Magnani IM Alvin Grayson-. EFTA00312738