Statement of Account

Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY "0021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description • WistPic :- ' . -44.146eopLats,AmiTaft); 04/08/2015 1 Last Payment Date ' Amount 04/08/2015 675.00 Paid by Paid By Charges Insurance Patient Adj. Balance 04/08/2015 04/08/2015 99214 17000 Est Pt Visit Detailed Dest I3en/Premalig 1st 500.00 175.00 500.00 175.00 7E0 PPFel Atit£ C NY 10321 T ID IItC~lID, 6D1193746 1133746 Ref I: 0311. Sale I - . awumill WEI EntrY IS: SiiiPed Total: $ 615.93 &4&4S 18:29:45 Inv t.: VW pear Code: - A;P:Nd: 0rloe Satc.4: " 30• • Curren, $0.00 T $0.00 $0.00 9'O Pays. ,ast. [Mel Notes: 91.'1:120 Days 'poii6ue > 120 Days Past Due $0.00 $0.00 Ratite ::*.kylri • $0.00 CUT ON DOTTED UNE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT POR YOUR RECORDS Please remit payment of $0.00 payable to: MITCHELL A KLINE, MD PC Statement Date: 04/08/2015 EFTA00317358