a, Mount Faculty Practice Sinai IF PAYING BY VISA, MASTERCARD, DISCOVER OR AMERICAN EXPRESS, FILL OUT BELOW Cen GEE) Cunsrancano Sem Clowcoven 1 Cavern hal TAR WM Doctors CARDIOVASCULAR INSTITUTE OF MO P.O. BOX 28083 NEW YORK NY 10087-8083 MUST CLUDE 9 CxGIT SECURITY COOK FROM BACK OF CARD __PAY THIS AMOUNT _ STATEMENT DATE _ ACCOUNT NO. 10113 | $55.00 | 26-3354934 FOR BILLING INQUIRIES: CHARGES AND CREDITS ADE AFTER srarevewrl SHOW AMOUNT $ DATE WILL APPEAR ON MExT STATEMENT. | PAIO HERE L mums MAKE CHECKS PAYABLE / REMIT TO: Mesgesl fA leg eg ALA egyffeteeffyetateaftadfeygy 102398142 CARDIOVASCULAR INSTITUTE OF MO 4 JEFFREY EPSTEIN P.0. BOX 28083 : ees 4 E£ 71ST ST NEU YORK NY 10087-8083 NEW YORK NY 1002}-4202 LeallMarsTaraboalsteatoalalloastisleallbesloallastall incorrect ns PLEASE DETACH AND RETURN TOP PORTION WITH DATE OF SERVICE + | DESCRIPTION OF SERVICE ‘i Q9967 PHARMACEUTICALS TOS CREDIT CARD PAYMENT * PLACE OF SERVICE 1 DOCTOR'S OFFICE 4 SURGI-CENTER 2 HOSPITAL 5 OTHER 3 EMER. ROOM Pate __|__ Patient Name _| _AscountNo | [THIS AMOUNT 16 DUE PAYMENTS RECEIVED AFTER THIS DATE APPEAR ON YOUR NEXT STATEMENT. Make check payable to : CARDIOVASCULAR INSTITUTE OF MO For all billing questions, call: 212-987-3100 “*PAY YOUR BILL ONLINE* Your prompt payment Is appreciated. If you have provided us with Insurance information, @_ You can now review your account details and pay your bills a was also sent to your medical carter. hae event that payment nerd you Vosemreae online, whenever it is convenient for you. ti Plaane for men DOMSgMO enclosed envelope. Login to https://www.mountsinai.org/mymountsinai and a ~ eee register. Once the account has been created, you can pay your bill using our new MyMountSinai Patient Online portal STATEMENT MOAN LE SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION soonse-y4a EFTA00313283

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IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... PATIENT INFORMATION INSURANCE INFORMATION Please Indicate if Applicable: CAUTO ACCIDENT COWORKER'S COMPENSATION “DETACH HERE AND RETURN ABOVE STUB” FOR HOSPITAL OR OTHER FACILITY PATIENTS YOU COULD RECEIVE TWO OR MORE BILLS FOR SERVICES PROVIDED TOTAL DIAGNOSTIC OR TREATMENT COSTS PHYSICIAN OR HOSPITAL CHARGES OR PROVIDER'S FEE OTHER FACILITY This statement is not a duplicate charge, but a separation of the facility and physician or provider's fees. These services were provided while you were under our care, or at the request of your other physicians or providers. Your bill from the facility may include a separate charge for use of its equipment, supplies, and technical personnel. You may also receive bills from other physicians or providers who were involved with your care if you were a patient in a hospital or other facility. If you have any questions concerning your bill, please call our office and we will be happy to assist you. iF YOU REQUIRE ASSISTANCE, YOU MAY CONTACT OUR OFFICE AT THE PHONE NUMBER ON THE REVERSE SIDE. PAP-201-C-0 EFTA00313284