BLUE SHIELD OF WESTERN NEW YORK, INC.

NOTARY PUBLIC

238 MAIN STREET

BUFFALO, NEW YORK 14202

SERVICE PROVIDED BY

MELISSA ERNSTEIN
AND MELISSA MOS
50 HIGH STREET
BUFFALO NY

SERVICE DATE

FROM

OFFICE

LOCATION

PLACE OF SERVICE

OFFICE

LOCATION

DESCRIPTION OF SERVICE

RADIOLOGY

CHARGES

TOTAL AMOUNT PAID

SUBTOTAL AMOUNT PAID

TOTAL AMOUNT DUE

AMOUNT DUE IN CASH

TOTAL AMOUNT PAID IN CASH

TOTAL AMOUNT DUE IN CASH

TOTAL AMOUNT PAID IN CASH

CLIENT: GRACE, BLOOMBERG

CERTIFICATE NO.: 13330502472

PLANING NO.: 0276138205536 BEC# 05-17-76

NOTICE NO.: 713801117

CLASS:

GROUP NO.: 920060000

DATE: 05-21-70

RECEIVED THIS FORM TO BE RETURNED. THIS IS THE ONLY COPY YOU WILL RECEIVE. IF YOU HAVE A QUESTION ABOUT THIS NOTICE, TELEPHONE US DIRECTLY, USING THE DIAL AND CERTIFICATE NUMBER LISTED ABOVE.

A-UNDER THE TERMS OF YOUR CONTRACT, BENEFITS ARE NOT PROVIDED FOR THIS SERVICE.

**************

YOUR DOCTOR WILL RECEIVE THIS EXPLANATION WITHIN THE NEXT TWO WEEKS, IF YOU HAVE
ANY QUESTIONS ABOUT THIS STATEMENT, PLEASE TELEPHONE US DIRECTLY.

GRACE, BLOOMBERG

150 MAIN STREET

BUFFALO, NY 14214