Unite dHe althcare Insurance Company — GREENSBORO SMALL GROUP () — PO BOX 740800 J SO ee nacene UnitedHealthcare = . = May 12, 2015 { Clalm information LE ‘Patient: Joffrey Epstein | = {Patient Acct #: 1 15289 UH = | Date of Service: 07/28/2014 | = | Provider: Dominick Cannavo, MD. _—— JEFFREY EPSTEIN | Claim 1D: 854905597/65/108422 = 6100 RED HOOK QUARTER B-3 : ‘Claim #: 4791351186 | ST THOMAS VI 00802-0000 | phenabee: Jattvay Epatein | MemberID: 854905597 ; | Group: SOUTHERN TRUST ! TN | Groups GAzT260S/NN000 ' fl ‘oup #: Deer Jelrey Epstein: ; \ | Letter ID: OvPToO1 | \, We make every effort lo process claims accurately, but sometimes errors occur. We overpaid you on a claim for you and need a refund. Please repay us $1,797.22 within 45 days of the date on this letter. Thank you and we apologize for any inconvenience this causes you Cisim overpayment details « Reason for overpayment: We didn't pay the correct am@unt for this sernice, * Check date: 11/12/14 / * Check number: QC09089752 « Amount of check sent to you: $1,797.22 (This amount may include other claim payments.) « Correct amount paid for this claim: $0.00 * Patient responsibility (what you owe) for this claim: $0.00 Mail your payment and this letter to: GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA, GA 30374-0800 We suggest you keep a copy for your récords. If we do not get the refund; Some state laws may allow us to deduct the amount due from future claim payments. You may have additional rights about this claim. For more information or further explanation, please check your Health Statement, Explanation of Benefits or other coverage documents. if you have questions about this letter or other questions related to your health insurance, please call the toll-free member phone number listed on your heaith plan ID card. Sincerely, UnitedHealthcare EFTA00311382

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re et en ee ee UnitedHealthcare 6 ‘A Unoaceatih Group Company = UnitedHealthcare Insurance Company ——s GREENSBORO SMALL GROUP — P © BOX 740800 = ATLANTA, GA 30374-0800 Have more questions about your claim? —— Visit www.myuhc.com = for all your claim and benefit information. = == May 13, 2015 —< 1348 ADADDRUHGPS0002001-05106-01 y _ JEFFREY EPSTEIN Member/Patient information 6100 RED HOOK QUARTER B-3 Member/Patient: JEFFREY EPSTEIN ST THOMAS, VI 00802 Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group # 0272605 Explanation of Benefits Statement This is nota bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). Doliar Amount Description Amount Billed $6,422.82 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts $600.00 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $5,822.82 This is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does nol include any payments made to the subscriber’. !f a payment was made directly to the subscriber, you/the subscriber is responsible for paying the physician, facility or other health care professional. * When coordination of benefits applies, this amount will include payments made to the subscriber. STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 4 (900000704873307 EFTA00311384

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ACU TUU ARS Fe a er rie fame UnitedHealthcare U = (A Unitadhinath: Group Company — UnitedHealthcare Insurance Compan GREENSBORO SMALL GROUP = P.O BOX 740800 —— ATLANTA, GA 30374-0800 Have more questions about your claim? = Visit www.myuhc.com == for all your claim and benefit information. = = 134BADADORUHGPS000200 1-05 106-03 May 13 2015 — ‘ = JEFFREY EPSTEIN Member/Patient Information 6100 RED HOOK QUARTER B-3 Member/Patient’ JEFFREY EPSTEIN ST THOMAS, Vi 00802 Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group #: 0272605 Explanation of Benefits Statement This is not a bill, Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). Doliar Amount Description Amount Billed $1,796.94 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts $1,432.98 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $251.40 This Is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any payments made to the subscriber. If a payment was made directly to the subscriber, you/the subscriber is responsible for paying the physician, facility or other health care professional, * When coordination of benefits applies, this amount will include payments made to the subscriber. STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 7 000000704673311 EFTA00311388

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EFTA00311393

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ee GREENSBORO LL GROUP PO BOX 740600 (| if: Le UnitedHealthcare I May 14, 2 Claim Information nd ors : Patient: Joff tein | PatlentAcct#: VVO' 13 Date of Service: 04/22/2015 | Provider: Mount Sinai Hospital Pile JEFFREY EPSTEIN | Claim 10: 854905597/EE/008273 6100 RED HOOK QUARTER 8-3 | lal #: 5036975306 ST THOMAS VI 00802-0000 i member: ‘eff tein i MemberID: ssancesbr : Group: SOUTHERN TRUST COMPANY Group #: GA272605/IM/000 Letter ID: SUBROO4 Dear Jeffrey Epstein: We received a claim for you for health care services on 04/22/2015. Before we can process the claim, we need to know if these services were related to an accident or injury. We work with Optum® on accident and injury claims to determine if we are to pay the claim or another insurance company is responsible, such as auto insurance or workers compensation. ff you have already been in contact with Optum or completed a questionnaire from UnitedHealthcare about this claim, please ignore this letter. You may receive additional letters if there is more than one claim related to the accident or injury. You only need to answer the questionnaire once. Please call Optum toll-free at MN between 7 a.m. and7 p.m. Central Time. Have the information below when calling. |s the claim due to an accident or injury? Yes or No. 1. If yes, you will be asked details about the accident or injury, including where or when it happened and when the condition started. 2. You will also be asked about any other insurance, such as auto or workers compensation What will happen next with your claim We are holding your claim for 45 days so thet you are able to provide us with the information needed. « Once we get the information, we will process the claim within 15 days. « If you do not respond within 45 days, unfortunately, we may have to deny the claim because of the missing information. We must process claims within time periods required by federal and state regulations. Thank you for your help. We look forward to taking care of this for you as quickly as possible. Sincerely, UnitedHealthcare UMAR LA EFTA00311394

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EFTA00311395

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GREENSBORO SMALL GROUP UnitedHealthcaré = P.O BOX 740800 Of) sven et coup corey = ATLANTA, GA 30374-0800 = www.myuhe.com UnitedHealthcare Insurance Company $= SS = = Address Change? Please i = S2SDADADORUN EPS DOONONT 0644-0 ‘al ompleyer's benelit department Member ID — JEFFREY EPSTEIN 854905597 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802 Statement Period 04/22/15 - 05/13/15 THIS IS NOT A BILL Customer Care Wear Sunglasses Ultraviolet (UV) rays from the sun cannot only hurt your skin but your eyes, too. Strong sunlight can burn the corneas of your eyes and long-term exposure can lead to eye disease, The best way to protect your eyes from the sun is to wear sunglasses designed to screen UV radiation, The good news is that sunglasses do not have to be expensive to be effective. Look for glasses that block 90 to 100 percent of both UVA and UVB light. Medical claims where payments may be needed from you: Pay your provider(s) when bill $27.98 Claims processed between 04/22/16 to 05/13/15 ‘94/24/18 services — JEFFREY provided by 'QUEST DIAGNOSTICS’ ‘Claim Number: 0504161738801 ;Provider Billed: $760.50 Payments and Discounts: ~$732.52 ‘04/24/15 services for JEFFREY provided by 'QUEST DIAGNOSTICS’ ‘Claim Number: 0504161738802 ‘Provider Billed: $378.86 Payments and Discounts; “$362.3 36 04/24/15 services for JEFFREY provided by ‘QUEST DIAGNOSTICS' Claim Number: 0504161738901 | Provider Billed: $657.58 Payments and Discounts: -$589.50 ~~ $1650 $68.08 $112.56 For more Information about these claims, | please | refer to the E: Explanation of Bonofits < or visit: YWorwmvuhe.com. ee This Is nota bill. Your provider will bill you directly unless you have already paid them. Plaase check your records. These charges represent your responsibility as defined by your health benefit plan. They may include your deductible, comsurance, or a product or service that is not an aligible expense. If you have coverage with another insurance carrier or Medicare, these charges may not include any product or service in which the other insurance carrier or Medicare was primary. In addition, the amount in the "Pay your provider(s) when they bill you” area above may include payments made to the subscriber. Please see your coverage documents for more information. Please see the next page for more information Page 1 of 4 UHG-0272605-00072611-P EFTA00311396

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Your Deductibles as of 05/13/15 for Plan Year 01/01/15 - 12/31/15 Out-of-Network Annual Applied Remaining Deductible: The deductible is the fied dollar amount that you pay each year =~) toward eligible heath care services before your plan benefits are payable. Once the deductible has been met, the co-payment and/or coinsurance JEFFREY $500.00 iy = SATISFIED | $0,00| period of your plan may begin. Please refer to your plan documents for - specific information regarding what services apply to the deductible. Your Out of Pocket Maximums as of 05/13/16 for Plan Year 01/01/15 - 12/31/15 In-Network Out-of-Network Annual Applied Remaining Annual Applied Remalning \JEFFREY = SS—~—SS—S————CCC*id*C«OG JEFFREY $2,50000 —$a00[__NONEUSED _] $2,800.00) | $500000 —svorei Mf) Sa.z0210 Out of Pocket Maximum: The out of pocket maximum is the dollar amount you pay pay bafore your your plan plan benefit starts paying at paying at 10096 for eligible health care. eligible health care services, Please refer to your plan documents for specific information on what coete apply to the maximum amount. Medical claims where payments are not needed from you: “Provider Pian Allowed | Health Plan Billed Discount Amount Paid Claim Number: 0470135118001 $6,000.00 ~$600.00 $5,400.00 -$5,400,00 Claims for JEFFREY Processed between 04/22/15 to 05/13/15 07/28/14 services provided by D CANNAVO' * THIS CLAIM WAS PROCESSED ON 05/12/15. * THIS PHYSICIAN OR HEALTH CARE PROVIDERIS OUT-OF-NETWORK. BASED ON AN AGREEMENT WITH MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THIS SERWCE. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND, 07/28/14 services provided by 'D CANNAVO' Claim Number; 0479135118801 $422.82 ~ $422.62 -$422.82 = THIS CLAIM WAS PROCESSED ON 05/12/15. + THIS AMOUNT REPRESENTS INTEREST PAID. For more information about your claims, please visit: www.myuhc.com. Please see the next page for more information Page 2 of 4 Customer Care UHG-0272605-00072611-P EFTA00311397

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138BADADDRUHGPS0002001-06144-02 Get the most out of your plan Website Registration: Register today online at www.myuhc.com, so that you can begin using your personal website! You'll need your ID card handy to register. The Dynamic Duo Benefits of taking a walk AQUA Vilamin D and calcium do more than give you strong bones and teeth, Several recent studies show that when taken together, vilamin D and calcium ward off premenstrual syndrome, It can also reduce the risk of colon polyps by up to 36 percent, and reduce the risk of Taking a walk can be a refreshing change of pace. The air can clear your mind and reduce stress, which can be helpful for weight loss. Research shows that stress can increase levels of cortisol, a hormone that may increase appetite and promote fat storage. Getting outside will help to decrease stress levels and feelings of hunger. hip fractures by 26 percent. On its own, vitamin D may reduce the risk of several cancers and calcium may help lower blood pressure. Add a glass of milk or orange juice to your diet to power up with this dynamic duo! About Your Rights You have the right to receive, upon request and free of charge, a copy of the intemal rule, guideline or protocol thal we retied upon in making the non-coverage decision for your claim, Medical or Pharmacy Claims Only A review of this benefit delermination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. The request for your review musi be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review not later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your Claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above, You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at es |: your plan is not governed by ERISA, you can contact the Department of Health and Human Services Healih Insurance Assistance Team at — i Your state consumer assistance program may also be able to assist you at: Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call Please call he number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in this communication. Please eee the next page for more information Page 3 of 4 Customer Care iy UHG-0272605-00072611-P EFTA00311398

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Maintaining the privacy and security of individuals’ personal information ic very important to ue at UnitedHealthcare. To protect your privacy, we implemented strict confidentiality practices. These practices include the abilityto use a unique individual identifier, You may see the unique individual identifier on UnitedHealthcare correspondence, including medical ID cards (Hf applicable), letters, explanation of benefits (EOBs), and provider remitiance advices (PRAs). H you have any questions about the unique individual identifier or ite use, please contact your customer care professional at the number shown at the bottom of this Statement Contact us Questions? You can reach Customer Care at our toll free number, EM, Monday through Friday or log into your personal website at www myuhe.com, Please see the next page for more information Page 4 of 4 Customer Care UHG-0272605-00072611-P EFTA00311399