EFTA00292239

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- MITCHELL A KLINE. MD PC 700 PARK AVENUE _ — NY 10021 JEFFREY EPSTEIN § EAST 71ST STREET NEW YORK, NY 10021 Date Frocedure Description 04/08/2015 99214 Est Pt Vist Detalied 04/08/2015 17000 Dest Ben/Premaiig 1s! Statement of Account Date Acedia 94/08/2015 04/08/2015 5 Paid by Paid By Charges Insurance Patient 590,00. 600,00 175.00 175,00 Notes: 1 REC Ay od GUT Gel DOTTED UNE ANG SEND Wii Payment be agenea= aS “EPSTEIN, JEFFREY ACCOUNTNO. ooo008048 | Statement Date. 04/082015 | Z 7 Please remit paymentof $0.00 payableto: MITCHELL A KLINE. MO PC eet To See yew & Miles Sale BAS Ine #: BRL frorvds Online feor Codes SRM batch: Be fsotome Coe trewe yar EFTA00292240

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MITCHELL A KLINE MD PC 788 PARK AVENUE "y YORK, NY 10021 Merchant 1D: 600051193746 Term Ib: 51193746 Ref : 8882 Sale Pertti Sil NEY Entry Method: Swiped Total: $ B00 05 0:23 Inv Hs 000082 Aoor Code: 527907 topryd: Online Batchtt: 008946 Customer Copy THANK YOU j : EO —| EFTA00292241