Life Steps Ob/Gyn Healthcare For Women, LLP 60 EAST END AVENUE New York, NY 10028 Phone 212-860-4800 Date October 21, 2016 I Account ID: 14159 Chart ID: 14159 Coverage Insurance Policy ID Nagnosls: A) N83.202 B) B37.3 SERVICES Date Claim-Line Provider X Ref CPT Units Mod Description Charges Payments Adjusts Balance 10/21/16 63491.1 Dr. Karen KIRSCH A,B 99212 1 Subseq. visit focused 175.00 0.00 Pad 10/21/16 Paid On: 10/21/16 Patient Payment - Cr 175.00 10/21/16 63491.2 Dr. Karen KIRSCH A,B 76830 1 450.00 0.00 Paid 10/21/16 Paid On: 10/21/16 Patient Payment-Cr 450.00 Balance : 0.00 RECEIPT Received *** $625.00 en Dollars Thank You I NEXT VISIT Date Time Duration Provider Location 11/10/16 11/18/15 11/18/16 12:00p 9:30a 9:45a 15 15 15 Mona Mona Lisa Touch PAM( SONO Kirsch Karen Life Steps Ob/ Gyn Life Steps OW Gyn Life Steps OW Gyn —4 O rt- •—• a - — C N V"‘` cae_cCers ConAeA\51/4\ cc mac aao se ar eScyr•ocirtr-s. EFTA00317140