STATEMENT

STATEMENT Thomas J. Ma Alvin Grayson Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: RIM pptiN by cmeM ant as dm maim you we woo W M trationa tat Led Soul baw. Maskaard Amex Conl a Up Ms moon SILI wr Date Account 10/29/2015 3114 Remittance IMPORTANT • PLEASE DETACH UPPER PORT ONNO RETURN NTH YOUR REMITTANCE TO lusts:et:war roPROPERACCOUIR Date Patient Description Charges Credits Balance 9/30/2015 9/30/2015 9/30/2015 10/20/2015 Jeff Jeff Jeff Previous Balance AMERICAN EXPRESS 3,000.00 525.00 220.00 220.00 3,220.00 3,745.00 3,525.00 Account Total 3,525.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the top part of this statement, or call the office Current 30 Days 60 Days 90 Days 120+ Days 3,626.00 0.00 0.00 0.00 0.00 Thomas J. MagnardlE. Alvin Grayson EFTA01122959 Thomas J. Mai Alvin Grayson Jeff Epstein 9 East 71st Street New York NY 10021 HISTORICAL STATEMENT 1/5/2016 to 2/24/2016 Telephone Date Account 2/24/2016 3114 Remittance PAPORTAAR . PLEASE DETACH UPPER PORTION AND REIM. WIN YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/25/2015 •re bus Balance 0.00 1/5/2016 Jeff 2,300.00 2,300.00 1/5/2016 Jeff 1,400.00 3,700.00 2/3/2016 Jeff 180.00 3,880.00 2/3/2016 Jeff 40.00 3,920.00 2/24/2016 Jeff AMERICAN EXPRESS 3,920.00 0.00 Account Total 0.00 Patient Charges 3,920.00 Patient Payments 3,920.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may complete and return the to rt of this statement, or call the office a Current 30 Days 60 Days 90 Days 120+ Days 0.00 0.00 0.00 0.00 0.00 Thomas J. Magma. Alvin GraysonM. EFTA01122960