DAD, PC

DAD, PC 108 PATIENT NAME PATIENT DUE BALANCE 590.001 59C.00 FOR BILLING INQUIRIES: PAGE:1 of 1 AGING AMOUNTS. IIIIIrhIIIIIIIIIIrIIhhIIllllllrlllPiIIIIilh 0-30: 31-60: 0.00 590.00 JEFFREY EPSTEIN 61-90: 0.00 301 EAST 66TH ST APT 11P OVER 90: 0.00 NEW YORK NY 10065-6217 228951D5OUTV000024.5 'minium um] DATE TRANSACTION PATIENT NAME AMOUNT Previous Balance: 590.00 001125 0101 Lor Mr:fin LUBLIAtithillth al farSflhI h If PAYING SY MASTERCARD, DISCOVER VISA OR AMERICAN EMPRESS, RLL OUT BELOW. PA I NT NAME PAT. A DUE PAID 590.00 Q Please chock box if your address Is Incorrect or has changed, and indicate change(s) on reverse she. JEFFREY EPSTEIN 301 EAST 66TH ST APT 11 P NEW YORK, NY 1CO65-621 CHECK CARD WINS FOR PAYMENT = MASTERCARD' = DISCCMER = VISA = AMERICAN EMPRESS CARO NUMBER SIGNATURE CODE SIGNATURE EXP. DATE STATEMENT DATE 6/1/2015 PAY THIS AMOUNT $590.00 ACCT. // Epstein, Jeffrey 328e6 PAGE: 1 of 1 SHOW AMOUNT PAID HERE 1551555 MARC S. LEMCHEN, D.M.D., P.C. NEW YORK, NY 100654108 328051050LHFVOXI2245 Iniumemummmenini EFTA00317364 009672 0101 PLEASE PROVIDE YOUR UPDATED INFORMATION SKINMEDICAL RESEARCH AND DIAGNOSTICS, PL o eL) D E,7j• O VISA U CHECK DOBBS FERRY, NY 105223520 34572 AUTHORIZATION CARD/CHECK NUMBER: F-1177 CODE TEMP RETURN SERVICE REQUESTED SIGNATURE: EXP. DATE: STATEMENT DATE: 04/29/2015 ACCOUNT NUMBER: PATIENT NAME: PAID AMOUNT': $ DUE AMOUNT: 280.00 For payments through credit card, full balance stud: be charged 6=16 MC unless an amount Is provkled. GUARANTOR NAME: PAYMENT DUE DATE: 05/20/2015 ADDRESSEE 301 E. 66TH STREET NEW YORK, NY 10065-6205 (JCheck this box If your address or Insurance Information has changed. F Indicate change(s) an the reverse of Nis page. Date of Service 04120/2015 CPT Code REMIT THIS PAYMENT STUB TO SKINMEDICAL RESEARCH AND DIAGNOSTICS, PL NY 10522-0042 Detach and return this portion with your payment. Please retain bottom portion for your records. 0P:ciiplIon Amount Pri Ins Sec Ins Other Ins Adjustment Patient Patient Charged Payment Payment Payment Payment Balance Previous Outstanding balance Mending Physician: MELISSA .GILL TISSUE EXAM BY PATHOLOGIST Primary Ins Rejection Secondary Ira Rejection Other Ins Rejection Totes for this Claim Total Amount Due PATIENT RESPONSIBILITY/REJECTION(S) SP - Self pay CONTACT US: FOR BILLING INQUIRY, PLEASE CALL AT (8:00 AM - 4:00 PM EST) 280.00 0.00 140.00 140.00 0.00 0.00 0.00 0.00 Total Amount Due: 0.0C 140.00 280.00 NUMBER OF DAYS PAST DUE 81-90 I $280.00 91-120 1 120+ 0.00 0.00 I 0.00 Receive Email Statements Register Today! O a tn. 6..o. 4, t. VISIT: EFTA00317365 fik PHYSICIAN SERVICES Mount Faculty Practice Sinai Doctors YOU CAN PAY YOUR BILL ONLINE TODAY! SEE PAYMENT OPTIONS Service Loc. ACCOUNT NUMBER Description OFFICE VISiT - LE E 3 TOTAL BALANCE AMOUNT 300.00 • .. : )V :ii SO Lit)* ^ r • PAYMENT OPTIONS I STATEMF.NT DATE 02/02/15 Payments/ AcljusimentS • Pay online at I MMIIMIM and register. Once the account has been created, you can pay your bill using our new MyMountSInal Patient Online portal. Pay-by-phon Hours of Operation: 9:00AM TO 5:00PM MON-FRI 2 Malt In a check payable to SURGICAL ASSOCIATES with the section below. _ _ _ •_ — . - Please detach lower portion end send payment In enclosed envelope. if paykig by Cala Cud please NI and below. l—1 0 a• O D.MEr - Mount Faculty Practice CARD NUMBER cw 0005 MOOED* Sinai SURGICAL ASSOCIATES 2r. Doctors EDICAL CTR SIGNATURE r tes nosiatower NEW YORKNY loon-area RETURN SERVICE REQUESTED D;;E SATri Receipt \ CCOU NUMBEti \ PAY THIS AMOUNT $300.00 C) PAY ONUNE A 11166” . NEW YORK NY 10065-6205 Total Amount Paid Here II> $ MAKE CHECK PAYABLE AND REMIT TO: SURGICAL ASSOCIATES EDICAL CTR NEW YORK,NY 10087-0668 _ EFTA00317366 KXd Palm Beach Pathology- Thank you for choosing Palm Beach Pathology for your health care needs. Statement Date: Responsible Party: Account Number: Due Date: REQUEST FOR PAYMENT Summary of Account Total Charges $ 212.52 Insurance Payments $ 0.00 Insurance Adjustments $ 0.00 Patient Payments $ 0.00 _Account Adjustments 0_00 AMOUNT YOU OWE $ 212.52 Your prompt payment is appreciatedl Please see the following paga for transaction details. Payment, Insurance, & Billing Information t r a o f Pay by credit card online E v i d d anytim e, 7day or night! Pay by credit card via phonca Certifled, safe and secare credit card processing. Visit us at wvvw.peryourhealth.com tgsupdate your insurance, address, vlew your accoat, or send a es offce. To contad the billing office, please cal( a 8:30AM-6:00PM EST Mon-Fri Para asistencia en Español liame el numero de arriba. pahn Beacsião~ Pathology- N CHARLF.STON, SC 29406 Temp - Retum Service Requested o o PAL*9141314044993C3806 tívp, 30i E 667H ST APT I18 ia? NEW YORK, NY 10065-6217 Page 1 of 2 Upon Receipt Important Message: Your account still has an outstanding baLagoe. Please payment immediately Tlrahl you frít,"O1-~t atforitiÁr)::: .^ 4 -Su cuenta refléja-un balance pendienté.-Per:favor-envic;-su-y- - -- pago para evitar futuras facturas. Apreciarnos su pronta atencion. This statement is for lab tests your physician ordered from. Palm Beach Pathology on your behalf. We are not affillétet with your physician. The balance is your responsibílity. Please make payment in full using a payment method listed to the left on the statement. ff you are melete to pay thefulp. amt, please contad our National Billing Office at ~.13 to dIscuss payment options. PLEASE DO NOT CALL YOUR PHYSICIAN REGARDING THIS STATEMENT. . No insuranoe coverage indicated for the visit showniabovk Pay By Mail Account Patient Statement Date Amount Due Due Date Amount Pelei 12/16/14 $ 212.52 Upon Receipt For your protection: Do not lndude the credit card information in the mal(. Make CHECK payable and remit to: — Please detach and retum bottom stub wlth your check — Include account number on oheck and correspondence ology EFTA00317367