RECEIVED 08/30/2017 12:32PM 2127174672 7ist St Pease emt abdhessed receipt Receipt date 98/30/2017 STUART I. ORSHER. M.0.. P.C Patient account # DIPLOMATE. 5G INTERNAL MEDICINE Patient name JEFFREY EPSTEIN 9 £ 79TH ST Amount due ¢ 9.00 New YORK, NY 10075-0123 Office phome: 212-535-7763 Amount enclosed $ DiEASE “SEND TOP-PORTIOH: TO: YOUR: INSURANCE: COMPANY JEFFREY EPSTEIN RETAIN BOTTOM: RIGHT PORTION-FOR- YOUR RECORDS - 9 EAST 71ST STREET ‘ SEND. SUTTON LEFT: PORTION: Wi TH_VOUR PAYMENT. NEW YORK, NY 10021 PAYMENTS REQUESTED: AT- TIME: OF SERVICE BLEASE RETAIN THIS-PORTION FOR YOUR TAX SECONDS. Please indicate any corrections to your sédress. Receipt cata 06/30/2017 STUART I. ORSHER. ™.D.. P.C Patient account # 010724 YOURS CREDIT-CARD-#:: ; Patient name JEFFREY EPSTEIN GATES OF EXPIRATION: : Amount due $ 0.00 CARD NAME» - STOATIRE, “Patient eccount# 9.0224 Bate of Birth: : _ R06.02 SHORTNESS OF BREATH SOE F = CARDIAC UHR GFE (COREG, $.— WETGHT GAIN: ABNORMAL Gokd d: HEYONRIDIDAL RESIDJA SIGE. TAGS 08/30/17 06/30/17 hay 99215-25 (5) PHYSICAL EXAM } | A.B.C . | 08/20/17 08/30/17 |11 | $3006 (S) EXG W/ INTERP } | 3 135.00 08/30/17 06/30/17 | 11 js40 S) PULMONARY FUNCTION | 8 | 135.00 | \eg/30/17 08/30/17 | 11 8006i-91 \ <S) LiPIO PANEL c 115.00 06/30/17 08/30/17 82948 {$) GLUCOSE STICK TEST | | Cc 45.00 08/30/17 08/30/17 63036 {$) GLYCOSYLATED (AIC) c .00 08/30/17 |s1000 (S) URINALYSIS-COMPLETE =| | | ase | 40.00 | | 08/30/17 06/30/17 ha1 3415 (S) VENIPUNCTURE A.B.C 45.00 08/30/17 08/30/17 | 11 |82270 (S) STOOL GUAIAC | | ) 6.00 08/30/17 i (F) AMERICAN EXPRESS | | 1490.00 | | } | | [PRYSICIAN OR PROVIDER So oo [STUART ORSMER. ™.D Maal 0 4/) 08/30/2017 (FERFORMED aT STUART ORSHER, M.D.. P.C NINE EAST SEVENTY-NINTH STREET NEW YORK. NY 10075 aoe ee > aragamant. ine Enqawood. New Jersey PLEASE PAY THIS AMOUNT EFTA00313719