Invoice Dentist in United States San Francisco –Free Word Template Download with AI
Comprehensive Dental Care in the Heart of the City
123 Market Street, Suite 400
San Francisco, CA 94105
United States
Phone: (415) 555-0199 | Email: [email protected]
Invoice Number: INV-SF-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To (Patient)
Jane Doe
456 Valencia Street, Apt 3B
San Francisco, CA 94110
United States
Phone: (415) 555-0123
Email: [email protected]
Patient ID: PAT-99281
Insurance Information
Primary Payer: Blue Shield of California
Policy Number: BS-CA-77889900
Group Number: GRP-SF-4455
Subscriber Name: John Doe
Relationship: Spouse
| Code | Description of Dental Services | Units | Fee | Amount |
|---|---|---|---|---|
| D0120 | Periodic Oral Evaluation - Comprehensive check-up including review of medical history and oral cancer screening. | 1 | $120.00 | $120.00 |
| D0274 | Full Mouth Series of Radiographs - Digital X-rays to assess bone health and detect hidden decay. | 1 | $250.00 | $250.00 |
| D1110 | Prophylaxis - Adult professional cleaning to remove plaque and tartar buildup. | 1 | $180.00 | $180.00 |
| D2391 | Direct Posterior Composite Resin Restoration (Tooth #19) - Tooth-colored filling for moderate decay. | 1 | $350.00 | $350.00 |
| D2392 | Direct Posterior Composite Resin Restoration (Tooth #30) - Tooth-colored filling for extensive decay. | 1 | $420.00 | $420.00 |
| D4341 | Periodontal Scaling and Root Planing (Quadrant 4) - Deep cleaning for gum disease management. | 1 | $300.00 | $300.00 |
| D9220 | Local Anesthesia - Infiltration for pain management during restorative procedures. | 1 | $45.00 | $45.00 |
| Subtotal | $1,665.00 |
| Insurance Adjustment (Est.) | -$1,100.00 |
| Insurance Payment Received | -$400.00 |
| Patient Responsibility | $165.00 |
Important Notes & Payment Terms
This invoice represents the financial responsibility for dental services rendered at our San Francisco clinic. As a premier dentist in the United States, we adhere to strict billing standards and transparency.
- Payment Due: The remaining balance of $165.00 is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge.
- Insurance: We have submitted a claim to your primary insurance provider. The amounts listed as "Insurance Adjustment" and "Insurance Payment" are estimates based on your plan's typical coverage. Final patient responsibility may vary slightly if the insurance adjudication differs.
- Payment Methods: We accept Visa, MasterCard, American Express, Discover, cash, and personal checks. Online payments can be made securely via our patient portal.
- Disputes: If you have any questions regarding this invoice or the dental procedures performed, please contact our billing department at (415) 555-0199 within 10 days.
- Privacy: Your health information is protected under HIPAA regulations. This invoice contains protected health information (PHI) and should be kept confidential.
Thank you for choosing Bay Area Dental Specialists. We are committed to providing exceptional dental care in San Francisco and maintaining your oral health for years to come. Your satisfaction is our top priority.
Authorized Signature
Dr. Emily Chen, DDS
Lead Dentist
Patient Acknowledgement
I acknowledge receipt of this invoice and understand my financial responsibility.
Date: _______________
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