Paget bg) Quest Laboratory Invoice For sernces not included m your physioan's ba 4 b ia i S&S Diagnostics a . GAcnc wee 1760 #13 Customer S lisse TBR 1!9782384 . SE71ST NEW YORK, NY 10021-4102 Phone, Fax Vases DDensectsdanedEabasdeseMMssssbal scab sde dled Weekdays 6-200 - 5 PMEST Se Habla Espariol Please have your invoice available for reference, Laboratory Tests Were Requested By: Most Recent Insurance Claim Filed To: Referring Physician. WOODSON MERRELL, Insurance Name: Physician Address: 44 £.67TH STREET Insurance ID: NEW YORK NY 10065 Group Number: Lab Results and Diagnosis Questions Must Be Answered By Your Physician Pablent Name JEFFREY EPSTEIN Invoice Date" Poy} 15, 2011 Responsible Parly: JEFFREY EPSTEIN Amount Due: Date of Service: February 11, 2011 Payment Due Date: Seize Date Charge Mosicaid Paid id Paid | Pa oziwit je7aa1 [SEROLOGY $110.00 oatwat jas SEROLOGY $11000 | | 1 | ] | | j | | Tax |D: 16-1387862 ICD-9 Codes: 597 80 $220.00) $000] $0.00 $0.00 0.00 $220.00] Scrwces Pestormed by QUEST DIAGNOSTICS, TETERBORO.NJ “The CPT codes prowded are based on AMA guidelnes and without regard to Apeeihe payor requirements a 4 Please fold and tear payment coupon along perforation and remit wilh payment in ihe envelope provided A+ Ny 1.1000 Ad) Quest Lab Code: TBR & Diagnostics Payment ‘ Coupon LOG ON NOW. Pay your bill ontine se = Due Date: 03/12/2011 Invoice Number: 119782384 day or night at a Patient Name: JEFFREY EPSTEIN or call 1-800-631-1388 Quest Diagnostics also accepts VISA Please make your check payable to Quest Diagnostics you received an explanabon of benefits showeng your responsi billy 6 less than the SnOunt Shown On thes bill, please pay the lesser ammount To tully resolve your invace, please provide a copy of your explanalion of benefits MAIL PAYMENTS ONLY TO: QUEST DIAGNOSTICS INCORPORATED Be sure to include invoice number on your check PO BOX 71304 a PHILADELPHIA PA 19176-1304 ciate estaaalaaa i VvvslMNatocsaellanalalsossldeatbalbecesballlauatatitll Quett Daagnostes reserves the nght te assign tes recewabie to any of #5 attitstes nee Please provide your new address information on the back 017B8R15010119786238400022000402150100212b4419b0000009 EFTA00312711

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THIS IS NOT A BILL bg Quest & Diagnostics Dear Patient, We did not receive insurance information to file a claim on your behalf for laboratory tests we performed on the date of service indicated on your invoice. Kindly provide the information requested below so that we may submit a claim to your insurance carrier for payment. Please return this information to us in the enclosed envelope within 10 days. If possible, please attach a copy of the front and back of your insurance card. INVOICE:__ — NAME OF INSURANCE: NAME OF POLICYHOLDER: INSURANCE ID #: GROUP #: RELATIONSHIP TO POLICYHOLDER: POLICYHOLDER SS. #: PATIENT GENDER: MALE FEMALE PATIENT’S DATE OF BIRTH: POLICYHOLDER DAYTIME PHONE #: SSS We appreciate your attention to this matter. If you chose you may fax it to (484) 676-8788. If payment is required, please remit your payment and the payment coupon in the envelope provided. You can also visit www.questdiagnostics.com/bill and submit the information or make a payment. Thank you for using Quest Diagnostics. We look forward to serving you in the future. Sincerely, Patient Billing Customer Service QDX2031 @dx203 06.2008 EFTA00312712