STATEMENT OF ACCOUNT

STATEMENT OF ACCOUNT ACTIVITY Page I of I 06/08/15 Date Patient Dr Claim Wit Description Amount Patient Responsibility 06/08/15 01 Limited Oral Evaluation 175.00 175.00 06/08/15 01 Panoramic Film 175.00 175.00 06/08/15 01 I 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 lit GENERAL. ANESTHESIA, 1ST 30 MIN 575.00 575.00 06/08/15 0I GENERAL ANESTHESIA. ADDL 15 MIN 175.00 175.00 06/08/15 01 GENERAL ANESTHESIA. ADDL 15 MIN 175.00 175.00 ACCOUNT STATUS Current 3375.00 Dr. Over 30 CLAIMS IN PROCESS 0.00 Over 00 ' Over 90 0.00 0.00 Last Payment Date / / Year to Date Payments 0.00 Balance 3375.00 Amount Due _1 3375.00 Service Submitted Patient Dr Claim Insurance Company Type Amount Meek teach led Men 111E pontos of dateniat %eat, pa:nall AMOUNT ENCLOSED AMOUNT DUE 3375.00 Remit by Account Numbcr 06/18115 Visa MC Acct# Exp.Date Security Code Signature Amount -••••••• awn. ••••••.• swot Staten Island, NY 10314 New Yor ew o , 10019 EFTA00311404 From: lest° a all corn Subject: : Date: June 11, 1 re 11: To: Begin forwarded message: From: "Jeffrey E "<*e • arnail.corn> Subject: Re: Dat • June 11 at 11:01:48 AM EDT To: < > yes On Thu. Jun 11, 2015 at 10:18 AM. wrote: =needs to gciSt to Dr. or o ow up a er will make her appointment...Dr, told her to come back and see him when she is done with her as well...OK to make appointment with Dr. for her? please note The information contained in this communication is confidential, may be attorney-client privileged. may constitute inside information, and is intended only for the use of the addressee. It is the property of JEE Unauthorized use, disclosure or copying of this communication or any part thereof is strictly prohibited and may be unlawful. If you have received this communication in error, please notify us immediately by return e-mail or by e-mail to tyacation@gmail.corn, and destroy this communication and all copies thereof, including all attachments. copyright -all rights reserved EFTA00311405 From: Subject: une 8 Date: 8 2015 et 11:30 AM To: Reminder is havin receiving an invoice in the mat soon this morning with Dr.=..you will be EFTA00311406 From: Subject: MM IIIMM Date: May la 2015 at 927 AM To: Jeffre E ' gmtolcom Cc: a will now go see Dr.Mor at 9am on June 8th.... EFTA00311407