writs yang Jays! Inv ts GOO Spore: Online ‘Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description 01/22/2015 99205 |New Pt High Compiexity 01/22/2015 11100 |Biopsy/Skin, 1st 01/22/2015 | 17000 |Dest Ben/Premalig 1st 01/22/2015 | 17003 | Dest Ben/Premal 2-14 AiTunce A ALINE Pw ore 70 PARK AVENUE NEWYORK NY 16823 ferchant 10; a6051292453 Tere ib: 51382943 Ref Be O01 Phone Order Pe il Entry Method: Maiual $ 12 — foor Code: 200078 UR Charges 500.00 250.00 175.00 350.00 02/05/2015 1275.00 Paid by Paid By Insurance Patient 260.00 175.00 350.00 500.00. Adj. Balance rs rs ae Custoser: Cory THANK YOUt ONTACT meiiss- Qi Please remit payment of $0.00 PSTEIN, JEFFREY ACCOUNT NO. 0000008048 | Statement Date: 02/06/2015 payable to: MITCHELL A KLINE, MD PC EFTA00282964

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[4500 | UNITEDHEALTHCARE Lieve PO BOX 740800 HEALTH INSURANCE CLAIM FORM ATLANTA GA 30374 APPROVED BY NATIONAL UNIFORM CLaila COMMITTEE (NUCC) 02/12 7. MEDICARE MEDICAID TRICARE CHAMPVA, GROUP FECA OTHER | 1s. INSUREO Sp NUMEER [For Program in [tem 1) HEALTH PLAN __ BLK LUNG (Mecicare #3 |_| (Medicaid #} [”] (Sponsor's SSN} [| (Member tx] 1SSN or 1D) sy [| ao; | 854905597 2. PATIENTS NAME (Last Name First Narra, Micdie inital) 3 PATIENTS DARTH DATE 4 INSURED'S NAME (Lasi Nome, Frat Name, Middle Ineia) — EPSTEIN, JEFFREY 01°20 | 1953 FE EPSTEIN, JEFFREY 5 PATIENTS ADDRESS (No. Sirest) 6. PATIENT RELATIONSHIP TOINSURED —_—| 7. INSURED/S ADDRESS (NO. Steal) 9 EAST 71ST STREET Sett [x] Spoure[] Chad! ] vel | | 9 EAST 71ST STREET [erry reer ae" STAT RESERVED FOR NUCC USI = ~—erm NEW YORK NY NEW YORK NY aP ri AreaCode) | iP CODE ELEPHONE (include Area Code) 10021 10021 3. OTHER INSURED'S NAME (Last Name, Fire! Name, Micdie initial 70. 1S PATIENT'S CONDITION RELATED TO. Tf. INSURED'S POLICY GROUP OR FECA NUMBER 272605 3 7 UF ER | a, EMPLOYMENT? (Currord or Previous} WSUREDD DATE OF DIRT mM OD OYy _x~ Or kM 01 ! 20 | 1953 "ix f & RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) [& OTHER CLAIM ID (Designated by NUCC) Oe mM, RESERVED FOR NUCC USE ©. OTHER ACCIDENT? - © INSURANCE PLAN NAME OR PROGRAM NAME } [jyres XO UNITEDHEALTHCARE @ INSUNANCE PLAN Name © GGRAM NAMM Tog. CLAIM CODES (Designated by NUCC) 3. 18 THERE ANOTHER REAL TH GENEFIT PLANT YES [x NO — ityes, complats tens $. Sa, and Bd ~~ READ BACK OF FORM SEFORE COMPLETING & SIGNING THIS FORM 12. INGURED'S OR AUTHORIZED PERSON'S SIGNATURE | authorize | 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | euthorize the release cf any medical cr other Information necessary | PSYMANI Of medical benefits to the undersigned physician or euppliee for {0 DrOoeEE this claim | ako request payment Of government Denefite dither lo myselt oF to the party who eccepts assignment Servi0e8 Céscnbed below, Dalow, sicnep_ Signature on file pare 02 05 2015 sicnep 14, QATEO RRENTRLNESS, INJURY, or PREGNANCY (LMP) [15 OTHER DA 16, OATES PATIE! LE TO WORK IN CURRENT OCCUPATION a) MM 90 | YY MM 00 YY WM DD OYY —_ : QUAL ‘QUAL. FROM ! To 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE il | ™~t~‘Y 78 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | MM DD OYY wa DD YY 17b) NPI FROM | To | [TS"AGBITIONAL CLAIM TINFORMATION [Designated by NUR 20. OUTSIDE LAB? S CHARGES yes = [X)NO [71 DIAGNOSIS OR NATURE OF LLNESS OR INJURY (Relais AL, w venice Tne Baw TIE] — ping 1 O | HE BRRyOMSSION Sauer hn | A 2362__ g. 7020 c D en Fo 6 Ht___.____ [= PRORAUTRORZATIONNOWEER a —___._4 ——— ane : ~ 24 A DATE(S} OF SERVICE 8 ¢. | D. PROCEDURES, SERVICES OR SuPPLES E r TET. n “| From Te PLACE OF {Explsin Unususi Circurstances) ClAGNOSIS POR |EESO"| 10. | RENDERING MM DD YY MM DD__vy_|SeRWICE| EMG _CFTIKCPCS MODIFIER POINTER S$ CHARGES swits| Pian |QUAL! _p>ROWIDER ID. # |_| py] NPI 1932136231 22 15 | 01 “orl 36231 _ |__| 0 22 1 OT: 22, 15 | 11 000 2) 5 1 00 4 NP! [19327362 _ , | OF aa 6 TOT ae eT TN | POS B88] TET : ys SS SU |_| | 3 7 25 FEDERAL TAX Nuweer SSN 36 PATIENTS ACCOUNT NO. 27 ACCEPT ASSIGNMENT? | 28 TOTAL CHARGE 23. AMOUNT PAID | 30. Revd for NUGG Use 133843772 x 0000008048 [] ves NO r) 1275,00 |, 1275'00 [OT SIGNATURE OF PHYSICIAN OR SUPPLIE! 5D. SERVICE FACILITY LOCATION INFORMATION 3. BILLING PROWIDER INFO 2 P 212 517 6555 INCLUDING DEGREES OR CREDENTIALS i i {ort tat te steers on tne revatee Mitchel A Kline MD MITCHELL A KLINE MD PC Spply to this bill snd are mage & part therect.) 700 Park Ave 700 PARK AVENUE MITCHELL A KLINE MD PC New York NY 10021 NEW YORK NY 10021 a SIGNED 02 06 2015775448038 |v 21154489318 |e. NUCC Instructon Manual available at www.nucc org PLEASE PRINT TYPE ROVED OMB-0038-44 1500 (02-12) EFTA00282965