02/11/2016 13:34 MUSIKANT DEUTSCH PC PAGE 01/02 PRACTICE LIMITED TO ENDODOMIC3 C. STEVEN D KAPLAN, D.M.D. ALEN 4K0B, D.M.D. PRACTICE LimIrmo TO ENOODONTICS FAX CO 119 WEST 57 STREET SUITE 700 NEW YORK. N.Y. 10019 ER LETTER Date: c;- IL Lk To: 2 ( it i From: ;( k :-,(eiLJ“ ---31 ../ .i, Number Of Pages Including This Cover Sheet cr:› Comments: I--s\!;._ 17— #(17--, CCOICLALVZ-51C "L-12-• CA- C--ap t-1 .-1 1C1 -4011.1-et/t. OtfrCW, -_--i---- cei,.4 DNS EFTA01085315 02/11/2016 13:34 MUSIKANT DEUTSCH PC PATIENT rParto- arsteast PAGE 02/02 Steven D Kaplan, DMD 119 West 57th Street Suite 700 New York NY 10019 DATE 02/11/2016 nal PATIENT DESCRIPTION CHARGE CREDIT EXPECTED INS PATIENT CHARGE 02/11/2016 Steven L'. Kapian LIC. 03416: Ta.x 25C0.00 ID. 13 3161736 3 .00 2500.00 SUMMARY INSURANCE PATIENT ADDITIONAL iNFORmATIOWAPPOINTMENT SCHEDULING PREVIOUS ACCOUNT BALANCE .00 .00 CHARGES FOR TODAY'S VISIT .00 + 2500.00 PAYMENT .00 CURRENT ACCOUNT BALANCE .00 2500.00 TOTAL OBLIGATION 2 500.00 PLEASE PAY THIS AMOUNT --> 2500.00 If your insurance company pays more than evaded, you win be credied the difference. It your insurance company pays less Than expelled, you will be charged the difference. Final nesponsibdity for payment refits with the person to whom this receipt is addressed. EFTA01085316