InstaMed® - InstaMed Patient Payment Portal

InstaMed® - InstaMed Patient Payment Portal - Receipt

To: "http://dummy.us.eu.org/robert" <http://dummy.us.eu.org/robert>

Subject: InstaMed® - InstaMed Patient Payment Portal - Receipt

From: "http://dummy.us.eu.org/robert" <http://dummy.us.eu.org/robert>

Date: Sat, 10 Jan 2009 16:01:29 +0000

Delivery-date: Sat, 10 Jan 2009 08:01:27 -0800

Envelope-to: http://dummy.us.eu.org/robert

Title: InstaMedÂ - InstaMed Patient Payment Portal - Receipt

https://pay.instamed.com/receiptPopup.aspx?id=EPAssoc&type=auto

Emergency Physician Associates

box 4419

Woodland Hills,CA 91365-4419

818-340-9988

Patient Name : ROBERT
Account # (not Tax ID#) : 61333738

Credit Card Sale

--- APPROVED ---

Response Message : APPROVAL
Response Code : 000

Jan 10 2009 8:00:00 AM

Card Type : MC
Card Holder Name : ROBERT
Card Account # : ************9142
Tran Amount : $598.00
Auth Code : 005051

I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT.

Have a nice day!