STATEMENT iF PAYNG BY CREDIT CARD, FILL OUT BELOW cS tea OISCOVER AM EXPRESS = _ a PLEASE MAKE CHECK PAYABLE TO: SEAN E MCCANCE MD 1155 PARK AVENUE NEW YORK NY 10128-1209 G ne STATEMENT DATE PAY THIS AMOUNT Ow AMOUNT PAID HERE 12/31/13 a0 | CHARGES OR PAYMENTS MADE AFTER CLOSING DATE WILL NEW YORK NY 10021 APPEAR ON NEXT STATEMENT. RESPONSIBLE PARTY: JEFFERY EPSTEIN 9 EAST 71ST STREET Please check box if above address is incorrect or insurance information 0 hes changes, and indicate changes) on reverse side. PLEASE | DETACH Lesed RETURN TOP PORTION WITH YOUR PAYMENT _ RECEIPTS Receipts | RECEIPTS “ADJUSTMENT Thacance! Faia 12/03/13 | OFFICE VISIT NEW PAT MQD 500.00 25.00 475.00 Insurance paid you DUE FROM PATIENT 475.00 ** PAYMENT DUE UPON RECEIPT * THANK YOU ** EFTA00304839