STATEMENT Thomas J. Ma nani Alvin Gra son If Dung by endA cad. enter Na A-11MM you St CW00 r, Ma ""Zteva box 0,4 Ail Out below maskers/0 VLLe ____ Max CAM if En Dale Sc,. ,,, OP Code Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Date Account 1/7/2015 9293 Remittance IMPORTANT PLEASE DETACH UPPER PORTION ANO RETURN Mill YOUR REMMANcE TO INSURE' CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 1/6/2015 1/6/2015 1/6/2015 Previous Balance 40.00 180.00 600.00 0.00 40.00 220.00 820.00 Account Total 820.00 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 90 Days 120+ Days 820.00 0.00 0.00 0.00 0.00 i Thomas J. MagnanIM. Mtn Grayson-. EFTA01122978