DS9 Document EFTA00521138

A Mount 1 /4 Sinai Original Receipt. Clerk: CAPULA01 MOUNT SINAI HOSPITAL PFS (KEY)-010109001240-AMBULATORY ACCOUNTS PATIENT FINANCIAL SERVICES 160 WATER STREET NY NY 10038 010405804429, NY 10017 PHONE: 212-731-3100 Name: karyna shuliak Card Number: XXXXXXXXXXXX2086• Card Exp Date: XX/XX Card Not Present Transaction Type: American Express SALE Transaction Amount: $3346.35 Auth Code: 142703 AVS Reply: (Z) ZIP ONLY CW2 Card Code: (U}UNABLE TO PROCESS Ticket #: 308555857 Invoice #: 1712426832 Date: 01/26/18 02:28:20 PM CARDMEMBER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREIN AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARDMEMBER's AGREEMENT WITH ISSUER X SIGNATURE EFTA00521138