Invoice Dentist in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, FL 33131, United States
Phone: (305) 555-0199
Email: [email protected]
License No: FL-DENT-998877
Invoice Number: INV-2023-10-450
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To
Patient Name: Johnathan Doe
Address: 4500 Collins Avenue
City/State/Zip: Miami Beach, FL 33140, United States
Phone: (305) 555-0123
Insurance Provider: Blue Cross Blue Shield of Florida
Policy Number: BCBS-FL-882910
Payment Information
Provider: Dr. Elena Rodriguez, DDS
Provider NPI: 1234567890
Payment Method: Credit Card / Check / HSA/FSA
Bank Name: Bank of America
Routing Number: 021000021
Account Number: XXXX-XXXX-1234
| Code | Description of Dental Services | Quantity | Unit Price | Total |
|---|---|---|---|---|
| D0120 | Periodic Oral Evaluation - Comprehensive examination of the oral cavity and surrounding structures. | 1 | $120.00 | $120.00 |
| D0274 | Full Mouth Series of X-Rays - Radiographic imaging to assess bone health and tooth structure. | 1 | $250.00 | $250.00 |
| D1110 | Prophylaxis - Adult dental cleaning to remove plaque, calculus, and stains. | 1 | $150.00 | $150.00 |
| D2391 | Direct Composite Resin Restoration (Class II) - Tooth-colored filling for posterior tooth. | 2 | $300.00 | $600.00 |
| D9220 | Local Anesthesia - Infiltration for pain management during procedures. | 1 | $50.00 | $50.00 |
| D9910 | Emergency Visit - Unscheduled visit for urgent dental care. | 1 | $100.00 | $100.00 |
Terms and Conditions
This invoice represents the charges for dental services rendered at Miami Elite Dental Care, located in Miami, United States. Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge. Please make checks payable to "Miami Elite Dental Care". For electronic payments, please reference your Invoice Number.
Insurance Notice: The amounts listed above are our standard fees. The "Insurance Adjustment" is an estimated reduction based on your plan's negotiated rates. Final responsibility for payment rests with the patient until the insurance claim is processed. We will submit claims on your behalf, but you are responsible for any co-pays, deductibles, or non-covered services.
Patient Responsibility: By accepting treatment, you agree to pay for all services not covered by your insurance. If you have questions regarding your coverage, please contact your insurance provider directly. We accept most major dental insurance plans commonly used in Florida.
Privacy Policy: Your personal and medical information is protected under HIPAA regulations. We will not disclose your information to third parties without your consent, except as required by law or for billing purposes.
Contact Us: If you have any questions about this invoice or your dental treatment, please contact our billing department at (305) 555-0199 or email [email protected]. We are here to assist you.
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