$0.00 $0.00 Notes: CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTACT Patient Balance Due 11875.00 -iefrAs7-4 EPS IN, JEFFREY t(I q, ACCOUNT NO. 0000008048 Statement Date: 07/27/2016 Please remit payment of $875.00 payable to: MITCHELL A KLINE, MD PC /6 EFTA00316268 FIN