rig wth your payment addressed tor STUART I. ORSHER, M.D.. 2.¢. DIPLOMATE, BOARD INTERNAL MEDICINE 9 & 79TH ST NEW YORK, NY 10075-0123 Office phone: 212-535-3763 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Please indicate any corrections to your address, T. ORSHER. M_D.. P.C Receipt date 09/15/2017 STUART Patient account # 019224 Patient name JEFFREY EPSTEIN Amount due $ 0.00 PROCEQURE CODE Jo9viS/17 09/15/17 | 11 |906e8 | (S) FLUZONE QUADRIVALENT © | }09/15/)7 JAM (F) AMERICAN EXPRESS | | | | ! | | ipt Receipt data 09/15/2017 Patient account # 010224 Patient name JEFFREY EPSTEIN Amount due $ 0.00 Amount enclosed $ PLEASE SEND TOP PORTION TO YOUR: INSURANCE: COMPANY, RETAIN BOTTOM RIGHT ‘PORTION FOR 2 YOUR: RECORSS = SEND: BOTTOM: LEFT PORTION WITH YOUR PAYMENT. PAYENT 1S: REGU JESTED :AT Ses DE SERVIGE PL LEMS RETAIN THIS PORTION: FOR YOUR. TAX RECORDS YOUR CREDIT CARD #, DATE: OF EXPIRATION; CARD MINES e + SIGNATURE: x arctan nce rrmanini rere GEFFREY EPSTEIN: TRuseeece anaes of 102043. G4 /207%953- ENCOUNTER FOR INMUNTZATION Diagnosis for: | Patient pecount # Date of: Birth: - pots ane CHARGES CREDITS 4 : 95.00 PHYSICIAN OR PA STUART ORSHER, (SIGNATURE fallhin *) 09/15/2017 ‘PERFORMED AT STUART ORSHER, M.0.. P.C, NINE EAST SEVENTY-NINTH STREET NEW YORK. [NPENO. {PROVIDER 10. NUMBERS - — - ; 1497993462 127681 eerenerne| PROV NPT: 1245447999 —_ [PATIENT REFERRED BY : ‘ ee | [TAKIO NO, 13-3039913 NY 16075-0123 25/2017 09/157 2017-09/15/2017 tructured Mananement, Ine, mM * Engiewood, Naw Jareey 07627 EFTA00299760