Statement of Account

Statement of Account MITCHELL A KLINE. MD PC Date Account No. Page # 03/30/2016 0000008048 1 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK. NY 10021 Date Procedure Description Last Payment Date Amount 04/08/2015 675.00 Paid by Charges Insurance Paid By Patient Adj. Balance 03/30/2016 99214 Est Pt Visit Detailed 450.00 450.00 03/30/2016 11100 Biopsy/Skin, 1st 250.00 250.00 03/30/2016 17000 Dest Ben/Premalig 1st 175.00 175.00 03/30/2016 17003 Dest Ben/Premal 2-14 150.00 150.00 03/30/2016 96904 whole body integumentary photograpy 500.00 500.00 0 - 30 Days Current 31 - 60 Days Past Due 61 - 90 Days Past Due 91 - 120 Days Past Due > 120 Days Past Due $1525.00 $0.00 $0.00 $0.00 $0.00 Notes: Pat ent Balance Due $1525.00 CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 03/30/2016 Please remit payment of $1525.00 payable to: MITCHELL A KLINE, MD PC EFTA00316208 From: Subject: Jeffrey and d or WM, 2016 Date: March 29.2016 at 11:39 AM To: Bella Klein FYI...Jeffrey is going to see Dr. Magnani tomorrow at 9am and Dr. Kline at 10am (Magnani for a cavity and Kline is a dermatologist) EFTA00316209 2pa JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK NY 10021 D PC Statement of Account Date Procedure Description 03/30/2016 99214 Est Pt Visit Detaned 03/30/2016 11100 Biopsy/Skin. 1st 03/30/2016 17000 Dest Ben/Presiali9 1st 03/30/2016 17003 Dest EieNPrema12-14 03/30/2016 96904 whole body integumentary photograpy CUT ON DOTTED LINE AND SEND WITH PAYMENT Notes: FOR BILLING INQUIRIES CONTACT Cha Paid by es Insurance Paid By Patient Adt Balance 450.00 450.00 250.00 250.00 175.00 175.00 160.00 150.00 500.00 500.00 ,JEFFREY ACCOUNT NO. 0000008048 Statement Date: 04/07/2016 Please remit payment of $0.00 payable to: MITCHELL A KLINE, MD PC EFTA00316210 ergs :// tne rcha ore e nlerc ardco lineage nilaccountIrec e p#R0984906 $: MITCHESD PC 04/07/2016 0255:28 PM Ref #. 098490653755 Authorization Code: 123648 Total: $1,525.00 use Card Number. 37Z0000000(3001 Card Holder. JEFFREY EPSTEIN Question about this receipt? Call us at O 2016 MITCHELL A KLINE MD PC . Wt rights reserved. 417120162:56 PM ( EFTA00316211 VMS, J HEALTH INSURANCE CLAIM FORM APPROVED ay NACONAl. UNWORN CIA& CO44545F54 5' IN 0502 MCA I. t CAR CHANPVA (54ZnanTiritiekeasitEL(Soomer• Sria MN.* EPASTEIN, JEFFREY ma."'" 40.• mike - I9 EAST 71ST STREET ----- 11Y I NEW YORK 1.~r----- - I NY ;10021 ---ritiml~~---1 i j i~AiStiREDSNA IRc lasS° A; —1 -1° 4 P-A~E--"A i I -____ I I 0550.91--ePa~ 4.1 -- a DIPLOYMENT? (Cinr4 crPT991fli DM ®No b. AIJTO ACCIDENT? PVC& MORN iorninufgrerm or_________ G 'Ili DD NO 1_,J c. OMER ACCIDENT'? YES IyjNO REIERVED FOR NUCC 0SE PLAN PATENTS DAT 5441 9y 01 20 1953 PAT SHIP UitAA NAME "--6MCMirjr"-- ---- --19F-45—n~Cairenbiarahre9114~;37511-6TOTt41-- — I I I IX PATIEWTS OR AUTHORIZED PERSON'S SGNATuRE I 09.99~ thø Dini• d or0 m•ilicei ix oft inkenuoon 494•9010* TO prouit ID* ctlim9 I &so N944) pirTmin 44 ~rain Porisit. 0~99 T97944 or 99 IN, Tots van way ~ant gnatufe on file SIGNED Si O4 07 2016 DATE 440 SOO499 (A' u Oes — R ERVE FOR IILICC N CO r4 or PR N QUALI f 1 . OF FERRINc PkniCini OA OTHER SOUR c 272605 UNITEDHEALTHCARE P 0 80X 740800 ATLANTA GA 30374 taw s let8ER 854905597 4. IFAsuR OS ax EPSTEIN, JEFFREY i A PICA (For 'wens, o Name. IN" 49 • 4i fr-- 9 EAST 71ST STREET NEW YORK 10021 it *NUR PS UP OR CA STA NY . Q.10 1/2 8 ) MM 00 rr SEX 01 20 1953 A 0. 5SprananQ ) Latialer~ UNITEDHEALTHCARE is IS THERE MIOIWTRar 1YELialt . 10 Ir Yet ~A klieg 0. 94 Toxin 13 INS OR AUTIONDEO PARSONS aiii nj — TuRE /aanna--- POr~ Of ~al ~is to ZS until:awed itemcan acipierke sev,an &sots° bibs SIGNED itt USA 1.04441 0 K CLIRRDTTOCC PATON FR 504 OD 44 DO MMMM TO IYAYpN ua WA CO YY 'Aril ris MI6, /ORAL Italia' i TA or Not WORM.* ION <0~4 T i „___. TO • OUTS0E LAC* 5 CHARGES iT.-5~e NA 54XNES R iNJURnTriiiin YES Wrap 1 it r Ito iniii ( g581,444ssicie ORIGINAL RIT4 NO A. L0225 _ 8 I 0485 c.i I-510 PL._ EL F.1._.- I 0•`_ H. AUTIRRIZATION NUMBER L K I. 24 A. DAM) OF WNW! B. D O. PROCEOURES. SERvICES. OR SUPPt P.S. TO PLACE (41:4199 UrmiNal CA~TITACT•) SA 00 WMIA 00 1•I SCR= EMG CPTAICPCS MOWER C. F. DIAGNOSIS POWER $CIIMGES G. Da OAn N CP ', m a I. /0 QUAL J RU4012/bia) i i A 450 00 NPI 1932136231 03 30 16 I 30 16 11 N 11100 59 B 250 00 1 NPI 93 138231 NPI 19 21 16 03 30 . 18 11 17003 180 00 3 NPI 19321 1 ' 11 00 1 NPI 1 231 NPI FE 00441 TAX 133843772 WOMEN — GU PATIENTS ACCOUNT NO. 0000008048 ‘r.orgrjAISID904%.tirk yes NO 20 AL CHARGE $ 152500 29 $ 1525 PAP 00 TO R•941 NVCC Uu .3I SIGNATUR< OF PrPISICIAN CR SLR INCLUOIKO DEGREES OR CREOENDALS il 4•544~ Or 90444.44.4 Ont. mina «of Io Nis Oil end aromas pert 'Direct) MITCHELL A KLINE MD PC RVICE TA iLI L li A Kline MO 212 5178555 MiTCHELL A KUNE MD PC 04 07 2016 WNW OAT! $1154419318 a 41154489318 D. ACCICIPIUCA `.. . . Iie WO (02)12 NUCC InStruction Manual available at minv nue.CONI EFTA00316212