Invoice Dentist in United States Houston –Free Word Template Download with AI

Bill To (Patient)

Mr. James Anderson

456 Westheimer Road, Apt 12B

Houston, TX 77027, United States

Phone: (832) 555-0144

Email: [email protected]

Date of Birth: 05/12/1985

Insurance Information

Primary Payer: Blue Cross Blue Shield of Texas

Policy Number: BCBS-TX-99887766

Group Number: GRP-445566

Subscriber ID: SUB-112233

Relationship: Self

Service Location Notice: All procedures listed on this invoice were performed at our main clinic located in Houston, Texas, United States. This document serves as an official record of dental services rendered in accordance with Texas state regulations and federal healthcare guidelines. Description of Dental Services Rendered

The following table details the comprehensive dental care provided by our licensed dentist and support staff. Codes correspond to the Current Dental Terminology (CDT) standard used across the United States.

Date	CDT Code	Description of Service	Tooth #	Fee (USD)
10/24/2023	D0120	Periodic Oral Evaluation - Comprehensive check-up by dentist	-	$125.00
10/24/2023	D0274	Full Mouth Series of Digital X-Rays (Diagnostic Imaging)	-	$250.00
10/24/2023	D1110	Prophylaxis - Adult Dental Cleaning (Supragingival)	-	$150.00
10/24/2023	D2391	Direct Posterior Composite Restoration (Tooth #19)	19	$320.00
10/24/2023	D2392	Direct Posterior Composite Restoration (Tooth #30)	30	$320.00
10/24/2023	D4341	Periodontal Scaling and Root Planing (Quadrant 4)	Q4	$450.00
10/24/2023	D9110	Anesthesia - Local Infiltration (Numbing for procedures)	-	$45.00
10/24/2023	D9920	Emergency Dental Visit Fee (After-hours consultation)	-	$100.00

Subtotal for Services:	$1,760.00
Insurance Adjustment (Est.):	-$650.00
Insurance Payment Applied:	-$800.00
Patient Responsibility (Due):	$310.00

Payment Instructions & Terms

Please remit payment for the outstanding balance of $310.00 USD by the due date listed above. As a dental practice operating in Houston, Texas, we accept the following payment methods:

Credit/Debit Cards (Visa, MasterCard, American Express, Discover)
Cash or Personal Check (Payable to Houston Premier Dental Care)
Electronic Funds Transfer (ACH)
Flexible Spending Accounts (FSA) / Health Savings Accounts (HSA)

Important Patient Information

1. Insurance Verification: While we have submitted this claim to your primary insurance provider, please note that this invoice reflects our standard fees. The final amount covered by your insurance plan is subject to their specific policy terms, deductibles, and annual maximums. If your insurance denies coverage for any procedure listed, the patient remains responsible for the full fee unless otherwise stated in your signed treatment plan.

2. Late Payment Policy: In accordance with our office policies in Houston, Texas, accounts that remain unpaid beyond 30 days of the due date may be subject to a late fee of 1.5% per month or the maximum allowed by Texas state law, whichever is less. Persistent non-payment may result in the account being referred to a collection agency.

3. HIPAA Compliance: This invoice contains Protected Health Information (PHI). It is intended solely for the use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of action in reliance on the contents of this information is strictly prohibited under the Health Insurance Portability and Accountability Act (HIPAA) of the United States.

4. Disputes: If you believe there is an error on this invoice regarding the services provided by our dentist, please contact our billing department within 14 days of receipt. Please reference Invoice Number HPC-2023-8942 in all correspondence.

5. Tax Information: Please note that dental services in the state of Texas are generally exempt from sales tax. Therefore, no sales tax has been added to this invoice.

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