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800.8424085 Providers: 877-842-3210 orrenv.UnindHeallhcem0nleccore Medical Claims: P.O. B0%710800 ATLANTAGA 300701903 PR • stsPPRE - PO Boxie2s7. San Juan, PR M36-8297 . 2 U a m& •40Multinan .MA/FRE '-41'.`•.^44 Pearmactsts: 88B490-S416 Pharmacy Claims: 0akum% PO Box 29044 Hal Sprint, AR 71903

BOUTHg_RN TRUST 0QMPANY 6100 REO HOOK QUARTER, B-3 s-r THOMAS VI 00802-0000 UnitedHealthcare . -s 4 >002669 7080107 003082 J.EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802-0000 03082 7080107 0000 0002869 3519 116 EFTA00304634

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BOUTHg_RN TRUST 0QMPANY 6100 REO HOOK QUARTER, B-3 s-r THOMAS VI 00802-0000 UnitedHealthcare . -s 4 >002669 7080107 003082 J.EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802-0000 03082 7080107 0000 0002869 3519 116 EFTA00316314

842-2065 Providers: 877-842-3210 or www unitedHeaithcareonine.com Medical Claims: P.O. BOX 740800 ATLANTA GA 303740800 PR - MAPFRE - PO Box70297. San Juan, PR 00936-8297 ya. Sw Stay multipari MAPFRE cin.Rfct-s--A Pharmacists: 888-290-5416 Pharmacy Claims: OptumFtx PO Box 29044 Hot Springs, AR 719

t (city and state) Date: Arresting officer's signature Printed name and title EFTA01699603 OM A N13.LSd3 LL ssazienta 3 A3 Edd3P 62 /20 UnitedHealthcare Health Plan (80840) 911-87 26-04 Member ID Group Number: Member. SOUTHERN TRUST COMP, JEFFREY EPSTEIN Office: 520 ER: $200 Urgeare $75 Spec