This is a letter to a patient whose doctor wants the customer to fill out the insurance form if it is not an insurance that the doctor accepts.

Account # MA 8674

INCLUDE YOUR ACCOUNT # ON ALL CORRESPONDENCE

Jill Bennett, M.D. PC 08/02/2010

P.O. BOX 2759

Islip, NY 11751

800-828-2837 / 631-158-6030 Phone Hrs: Mon-Fri 10 AM To 1 PM

Richard/Marion Hall

35 Dover Lane

Bay Shore, NY 11706

For anesthesia or related services at Good Samaritan Medical Center

1000 Montauk Highway, West Islip, NY 11795

To Marion Hall On 07/06/2010 Amount $1,615.00

Payments received to date $1,502.40

Balance Due $112.60

I participate in certain Blue Shield plans, GHI, AETNA, Choice Care, Oxford, Trucare and Metro-Kingston. If you have health insurance through these carriers please send a completed insurance form for submission.

If you have coverage with any other carrier please send us a completed insurance form assigned to pay the doctor.

If there is not health insurance coverage please send your check by return mail.

This is a letter to a patient who was a crime victim. Most people don’t know that crime victims are eligible for free medical care.

Account # MA 8674

INCLUDE YOUR ACCOUNT # ON ALL CORRESPONDENCE

Jill Bennett, M.D. PC 08/02/2010

P.O. BOX 2759

Islip, NY 11751

800-828-2837 / 631-158-6030 Phone Hrs: Mon-Fri 10 AM To 1 PM

Richard/Marion Hall

35 Dover Lane

Bay Shore, NY 11706

For anesthesia or related services at Good Samaritan Medical Center

1000 Montauk Highway, West Islip, NY 11795

To Marion Hall On 07/06/2010 Amount $1,615.00

Payments received to date $1,502.40

Balance Due $112.60

Before applying for crime victims benefits, you must first apply to your health insurance carrier.

If you have health insurance, please send a completed claim form to our office assigning the benefits to pay the doctor directly and including the address of the carriers claim office.

If you do not have health insurance, please indicate your crime victims file number in the space provided below and return this bill to our office for processing.

Crime victims file#—————

This is a courtesy letter to a patient who has Blue Shield insurance.

Account # MA 8674

INCLUDE YOUR ACCOUNT # ON ALL CORRESPONDENCE

Jill Bennett, M.D. PC 08/02/2010

P.O. BOX 2759

Islip, NY 11751

800-828-2837 / 631-158-6030 Phone Hrs: Mon-Fri 10 AM To 1 PM

Richard/Marion Hall

35 Dover Lane

Bay Shore, NY 11706

For anesthesia or related services at Good Samaritan Medical Center

1000 Montauk Highway, West Islip, NY 11795

To Marion Hall On 07/06/2010 Amount $1,615.00

Payments received to date $1,502.40

Balance Due $112.60

Please complete enclosed form and return promptly. Please advise whether or not you have major medical coverage as well. If you do please send form, promptly completed and assign payment to the doctor, your benefits will be payment in full.