STATEMENT

STATEMENT Thomas J. Ma nani Alvin Gra son If Dung by endA cad. enter Na A-11MM you St CW00 r, Ma ""Zteva box 0,4 Ail Out below maskers/0 VLLe ____ Max CAM if En Dale Sc,. ,,, OP Code Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Date Account 1/7/2015 9293 Remittance IMPORTANT PLEASE DETACH UPPER PORTION ANO RETURN Mill YOUR REMMANcE TO INSURE' CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 1/6/2015 1/6/2015 1/6/2015 Previous Balance 40.00 180.00 600.00 0.00 40.00 220.00 820.00 Account Total 820.00 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 a Current 30 Days 60 Days 90 Days 120+ Days 820.00 0.00 0.00 0.00 0.00 i Thomas J. MagnanIM. Mtn Grayson-. EFTA01122978 Thomas J. Ma • Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New York NY 10021 TelephonE per; by twit cwt. enter Mt mount you so POW( Saul below Masten:DM Vest Amax Coda Slutture Date 7/29/2015 IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR RIENTTANCE TO aasuaa CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits 7/1/2015 7/1/2015 7/1/2015 J . 4• •ce 40.00 180.00 Account Total 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 at 212-688-1090. Current 30 Days 60 Days 90 Days 1 220.00 0.00 0.00 0.00 Thomas J. Magnant.l. Alvin Grayson.. EFTA01122979 STATEMENT Thomas J. Ma Alvin Gra son Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Par,n0 by CroSi ord. only to ernaxI yea: ara Par4^9 In r'e romitonc• WI end 14 out Won. Itestettrrd 1s Pena Cwda Exa Oita Scaturo Sig Cole Date Account 3/2/2016 9293 Remittance IIIPORTANT - PI FACF DETACH UPPER PORTION AND RETURN WTH YOUR REIATTMVE TO TISURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 1/27/2016 2/17/2016 2/17/2016 nce 40.00 180.00 0.00 40.00 220.00 Account Total 220.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may comple p part of this statement, or call the officetiiiiiiiii Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Paagnanl =. Alvin Grayson-. EFTA01122980 STATEMENT Thomas J. Ma . Alvin Gra son II mina by artell cent enter Ile ert16., 4 you on fl ing In Pto rernierneto Nee and fie cabelcw. Mmtercard Vaa Amax Cord • Tv Date Sgvlua SO CO:e Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Date Account 3/30/2016 9293 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN LATIN YOUR RENUTTNCE TO P4SURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/2/2016 220.00 3/17/2016 220.00 0.00 3/22/2016 125.00 125.00 3/22/2016 30.00 155.00 3/22/2016 450.00 605.00 606 Account Total 605.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the to • •art of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 605.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl M . Alvin Grayson EFTA01122981 STATEMENT Thomas J. Ma Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New York NY 10021 IT parity midi Taft nil. Maya MN Ere psylng MEE nmilammi box • ad META Flasined NM Mat Cede Exp Dill Scan SiDade Date Amami 10/29/2015 9293 Ramitanee IMPORTANT - INCASE DETACH LETITCR PORTION MID RETURN WIN YOUR REMITTANCE TO EPSIJRC CRUET TO PROPER ACCOUPR Date Patient Description Charges Credits Balance 9/30/2015 10/612015 10/6/2015 10/13/2015 Previous Balance 450.00 450.00 275.00 0.00 450.00 900.00 1,175.00 Account Total 1,175.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and r turn e t part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 1,175.00 0.00 0.00 0.00 0.00 Thomas J. /Mona& Nu Akin Grayson EFTA01122982