Guarantor:

Guarantor: Julia Cuomo Patient: Julia Cuomo Weill Cornell Physicians 575 Lexington Ave. Suite 540 New York, NY 10022-6102 0000001,0050866700000070000 7650 1 AV 0.378 Statement Date 02/20/2015 YOU C O visa Card Number Cardholder Name Signature D MasterCard Amount Due AMOUNT ENCLOSED $70.00 AT WWW.WEILLCORNELL.ORG D Discover D American Express Exp Date INV# 1356276 MRN# 74751028 MAKE CHECKS PAYABLE AND MAIL TO: Weill Cornell Medical College GPO Box 28375 New York, NY 10087-8375 DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT. IF ADDRESS OR INSURANCE INFORMATION IS INCORRECT PLEASE INDICATE CHANGE(S) ON REVERSE SIDE. Weill Cornell Physician Organization At NewYork-Presbyterian/ Weill Cornell STATEMENT OF PROFESSIONAL SERVICES AS OF FEBRUARY 20, 2015 Tax Identification: 13-1623978 Account Number: 100508667 Medical Record #: 74751028 SUMMARY TOTAL AMOUNT DUE $70.00 An Important Message Regarding Your Account Your account is past due and requires your immediate attention. To avoid further collection activities, please remit payment in full. 111 I 01/14/15 88175 Pap Test Visit Number: 1 Provider: Rana Shafiq-Hoda, MD Weill Cornell Pathology Location: Office Referred By: Lauren P Feit, MD Diagnosis Code(s): V76.2 70.00 Total $70.00 Payment Activity 01/14/15 Total Charges Patient Balance Due $70.00 $70.00\ EFTA01196687