1500 HEALTH INSURANCE CLAIM FORM A"'".'et' I • 4•0. 444 4%. -...,• 9 . 4, o•tart ILL N --..:1:A/[ ' nit • IC. Nic nr. ottA O!..t. t ACM itt With "..11/44 ,imakr• • 144.A4441 tfa•Am OM I Aisne 921,„_*" • 4'. ' - thAnD41"3 *ace liters ••11.1rw Mai I ciihrot EPSTEIN. JEFFREY • •41444-1 sass I. 44 cower 9 EAST 71ST STREET • NEW Mo. :cc.4 1CO21 • Z•wilil Z J 'Oak ran I14/ 3.-• Ian. h.• pLA 3 • • _ • rkimer ahron• sog ctMt 41- tiMr•t-7+50* 14 NY It I . ••,...A I..4• •;114;10V-CN Wei GWAA' MAWR 4 WitioWeS 44:44i.a v. NO4, a.. onat to • eitialikaitia Matto to • I luratOat4. 4.4•44 • Petwasj , so to trIcrin. e.ta 'Oat X 4D _ -, ono act COW • al it IC e..Cm'eSi4o — Aga Wei oi NAY Watt ON" t 0.44.140 Isle IOW • At attars & AO:Walt 4tta.te tat On ••••••••••) A roe,. •••• 4•4,.. 4.4. -not ~-4..4 crew. 4.440'4, a 4. n 44.4. Asia **ern [ tem wan° SIFIAIUM 071 61• tars 04 08 2016 • tot NI I. CA/41. • WOO/ ODTRA*4 araeigica ig‘ as - 1111. Y UNIT EOHEAL THCARE P 0 GOX 740800 ATLANTA GA 30374 is 042,40_Ct •AA4t. 854905597 a tan VI Mak 444 tio.•4 I.• t7•0 EPSTEIN, JEFFREY nikatifittAr.mmt sTiej 9 EAST 7I ST STREET _ e raliria• NEW YORK NY cid -10104704tarcum 10021 .. ADAC 0 441.<4 44004:64 iDATOAAICIO-: 2;7605 • Kneen paw on — ow co Iv lel Oft_ _ 20 1953. • 01 ;loyea•fatil./.WlT0•46— aat kr.:aitiaaliPki lia --- UNTTEDHEALTHCARE 134/ ti44a.aPaaaral@The1490-47VW-- It K3 LIL NO las 1.0•Ii• •••• Is 00441 hTe- ill a Auttareitialastals---awfulaiTharn Per tams Worm r vs ~one span or t at doetriatro• DtMO • ttp DO TT INI OWL, MOW M ft ( a *calor a tIltiTaretra trdiTtnia -- te0 at Ott at r 01 tat MU ID ' ii AZISTOVortai AGIMA0 0i3iireiliarital ;,-Atitititt i Cyle.arISABESI :1) zuscez.sa. ta.inr,≤ ,t - Nil g ... • i il• WAS IA *Attar (74 1:440 NI lateti747arti -sinVo 1W•••:-.094t a - ihT. r , 77 WILESICA titiVAAt an 40 A . 214C H i.____ ilii64 4;abir iall I I a _ TWO __ C 0 - C 4 . : — 1 • 2.A.. ti E i ,. 1 trcliplail "vas all --.1.3 ilint. 177. . I 11,..1;4., :7 „,..„0„,„....' .4 • clAtirs: 01 Ile/AOCI W H IN pea 4 l: i Y. 'WWI ' tit: :ettrJeCt ThrICCIVtla ipt4t..4.... 7 : oconch Iowan .•4 t, t-..- ' '/..'• - _ 5 . _ , I •"11. Oa bi;. te 36 cCaOtt- Is • 11 74 922 14 2 : ... - • A 6cio—iio .. 1 . i ail hiiiiiiiiiiii PI -- 17000 8 175 CO 1 . wig.1. t02213-62.il 04 et 15 CA Oil 15 II osibiailes-Liaar kvi , 4 4, —Jo Alia tt.. 133143772 • t WIIIIInnabai• Vinfi —tlfltiMer OURS tin 0 es at COMM 04 OlittwOall I Macho A kIlato to arm Po ItQ ler err4 Li Ks, irk MD PC ••• ....• eh•• yr ono L 703 Pm• Ms Nat York NY 10021 04 OS 2015 tguicti ti • bin fateast apps, pa t/P1 [ 1 WI ,- i I ' NPI :::t •. • - — EVA 675 00 a 676 00 I •,I w...mu-WOgnu 21-2- MI ItHELL A KI.IP•IE MO PC 700 PARK AVENUE tIEW YORK NY 10021 has 0040aral tar ISM tile MI EFTA00292239 HI E N :• 4.1 n. Statement of Account MITCHELL A KLINE. MD PC 700 PARK AVENUE Y RK NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description 04/08/2015 99214 Est Pt Vis4 Dstatled at/08;201s 17000 Dest SentPremalg 1st Date 0403/2015 ACCOtrft, 0000001 Last PAY-client a ?TOO 04(0E/2015 Charges 500.00 175 00 Paid by Paid By Insurance Patient 0 -30 Days 3 - 60 Days 01 - 90 Da9191 - 120 D aysl T 120 Days Currant , Peal Dab Past Due Past Due Past Due - - 3000 SO 00 I SO 00 SO 00 —T Notes: $0.00 CUT 014 con El) ONE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTAC 500.00 175.00 lien III. POWS 1 B11011060', SO DO EPS1EIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date 04/08:2015 Please remit payment of $0,00 payable to; MITCHELL A KLINE. MD PC EFTA00292240 MITCHELL A KLINE MU PC 700 PARK AVENUE NE YORK. NY 10021 Merchant ID: 000051193746 Term ID: 51193746 Ref P: 0002 Sale mama AMEX Total: 04/08/15 Inv 4: 000002 APPrvd: Online €ntry Method: Sniped $ 850,00 11:07:29 APPr Code: 527907 Batchif: 000946 Customer COPY THANK VOW EFTA00292241