STATEMENT

STATEMENT Thomas J. Ma Alvin Grayson MOM Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone twang Im HAM mut •Alm me Mean yea am MOON TA MoglanOitOX " SI an tam Main* Ma tan Cadl exv sonoo. so CNN Date Account 3/26/2015 10918 Remidenee IMPORTANT • Pt EASE DETACH UPPER PORTION NO RETURN PATH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 2/26/2015 Previous Balance 0.00 2/26/2015 60.00 60.00 2/26/2015 180.00 240.00 2/26/2015 12.00 252.00 2/26/2015 175.00 427.00 3/2/2015 180.00 607.00 3/5/2015 450.00 1,057.00 3/5/2015 475.00 1,532.00 3/5/2015 450.00 1,982.00 3/9/2015 425.00 2,407.00 3/9/2015 425.00 2,832.00 3/17/2015 475.00 3,307.00 3/17/2015 475.00 3,782.00 3/19/2015 425.00 4,207.00 Account Total 4,207.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the top part of this statement, or call the office a Current 30 Days 60 Days J 90 Days 120+ Days 4,207.00 0.00 0.00 r 0.00 0.00 Thomas J. Mammy= Alvin Grayson M. 7 EFTA01122952