STATEMENT OF ACCOUNT Page | of | ACTIVITY 06/08/15 Date Patient Dr = Claim Tht Description Amount Patient Responsibility 06/08/15 01 Limited Oral Evaluation 175.00 175.00 06/08/15 ol Panoramic Film 175.00 175.00 06/08/15 ol | | Surgical Removal Comp Bony w Compli 700.00 700.00 06/08/15 01 16 Surgical Removal Comp Bony w Compli 700.00 700,00 06/08/15 01 32) Surgical Removal Comp Bony w Compli 700.00 700.00 06/08/15 01 GENERAL ANESTHESIA, IST 30 MIN 575.00 575.00 06/08/15 0! GENERAL ANESTHESIA, ADDL 15 MIN 175.00 175.00 06/08/15 01 GENERAL ANESTHESIA, ADDL 15 MIN 175.00 175.00 ACCOUNT STATUS ,), i | __ Current_ J Over 30 | Over 60 Over 90 [Last Payment Date] Year to Date Payments Balance Amount Due { 3375.00 0.00 | 0.00 0.00 | /f¢ | 0.00 3375.00 3375.00 CLAIMS IN PROCESS Service Submitted Patient Or Claim Insurance Company __ Type Amount -] AMOUNT ENCLOSED AMOUNT DUE es cc Visa__MC__Acct# Exp.Date__ Security Code_ Signature Amount Staten Island, NY 10314 New York, New York, 10019 EFTA00311404

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From: lesley jee@ gmail com Subject: Date To: Begin forwarded message: From: "jeffrey E.” <jeevacation@gmail.com> Subject: Re = Date; June 11, 2015 at 11:01:48 AM EDT yes On Thu, Jun 11, 2015 at 10:18 AM f | eeds to go back to Dr t to come back an sase note nation contained in this communication is may be attorney nt privileged, may 2 informat and is intended only for e addressee. It is the property of communication or any part and may be unlawful. If you have re communication in error, please nc return e-mail or by e-mail to jeevacationG dG this co inication and all copies thereof sluding all attachments. copyright -all rights reserved will make her see him when she is done with her as well...OK to make appointment with Or. [J for her? EFTA00311405

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To Reminders da i morning with Dr. you will be receiving an invoice in the mail soon! From Date — 2015 at 11:30 AM EFTA00311406

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From: Subject: Dr Date: May 13, 2015 at 9:27 To: Jeffrey Eps sevacation @omail com — —_—_— qi will now go see hm” Ti i at 9am on June 8th.... EFTA00311407