MAKE CHECKS PAYABLE TO Peter Rubin M.D., P.C. 920 Park Ave 1N New York, NY 10028-0208 ADDRESS SERVICE REQUESTED ADDRESSEE Jeffrey Epstein 9 East 71 Str Ny, NY 10021 O None Gook too ff aboto onicoss cs wowed or Ammo ild0rMatiCal ha, dhatidad, and iataCata CIMINES) on towns WO IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS. FILL OUT BELOW CHECK 0 DISCOVER CARD USING FOR PAYMENT 0 VISA lil • MASTERCARD AMERICAN EXPRESS CARD NUMBER AMOUNT SIGNATURE EXP. DATE STATEMENT DATE 12/01/2018 PAY THIS AMOUNT 1,100.00 ACCOUNT NUMBER 5855 PAGE NO. 1 SHOW AMOUNT PAID HERE $ REMIT TO Peter Rubin M.D., P.C. 920 Park Ave 1N New York, NY 10028-0208 STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Date Ins. Patient Date Billed Code Dr Description Diag. Charge Ins. Pmt. Pat. Pmt. Adjust. Balance 07/30/18 Jeffrey 43239 PHR Egd Wlbiopsy R07.9 1,100.00 0.00 0.00 0.00 1,100.00 Current 0.00 31 - 60 Days 61 - 90 Days 91 - 120 Days 0.00 0.00 Over 120 Days Total Balance Ins. Pending 1,100.00 1,100.00 0.00 Patient Due 1,100.00 Doctor Codes PHR Peter H Rubin, MD Make Checks Payable To: Peter Rubin M.D., P.C. 920 Park Ave 1N New York, NY 10028-0208 " Balance is overdue. Contact us or be referred to a collection agency. ** EFTA00316467