Statement of Account

Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description Date Account No. Page # 07/27/2016 0000008048 1 Last Payment Date Amount 04/07/2016 1525.00 Paid by Paid By Charges Insurance Patient Adj. Balance 07/27/2016 99205 New Pt High Complexity 500.00 500.00 07/27/2016 11100 Biopsy/Skin, 1st 250.00 250.00 07/27/2016 11101 Biopsy/Skin Each Additional 125.00 125.00 0 - 30 Days Current 31 - 60 Days Past Due 61 - 90 Days Past Due 91 - 120 Days Past Due > 120 Days Past Due $875.00 $0.00 $0.00 $0.00 $0.00 Notes: CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT Patient Balance Due 11875.00 -iefrAs7-4 EPS IN, JEFFREY t(I q, ACCOUNT NO. 0000008048 Statement Date: 07/27/2016 Please remit payment of $875.00 payable to: MITCHELL A KLINE, MD PC /6 EFTA00316268 FINANCIAL TRUST COMPANY 610 THOMASOK QUARTER. B-3 ST VI 00802-0000 t UnitedHealthcare' >000496 5742862 001 003082 J.EPSTEIN 6100 RED HOOK QUARTER 8-3 ST THOMAS VI 00802-0000 8 6 0 U O1II2 ST4ZIO fe011 110004 011006 0.2 I Ili EFTA00316269 Thank you for choosing UnitedHealthcare r3 Y 111111111111111111111111 ••••••• *MO. TN, cad &es no prove mernbenhiPnee PariabIlrfa•t•0• For Members: coy w. myuhc.com gggli;11741 Care24: Menial Health: 888-2654771 Fa Prowlers: yeauneedheallheareonhne.com 877.842-3210 Medical Claims. P.O. BOX 740800 ATLANTA GA 303740800 tai•3 soap ;11Munr^:.r Pharmacy Clalms:PO BOX 14711, LEXINGTON KY 40512 For Phrifinntig% 800.922.1557 I110011 110 01111011111110 HIM Ell EFTA00316270