Invoice Orthodontist in United States Chicago –Free Word Template Download with AI
123 Michigan Avenue, Suite 400
Chicago, Illinois 60601
United States
Phone: (312) 555-0199 | Fax: (312) 555-0198
Email: [email protected]
Tax ID: 36-XXXXXXX
Invoice Number: INV-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: September 2023 - October 2023
Bill To:
Patient Name: Sarah J. Thompson
Address: 456 Lake Shore Drive, Apt 12B
Chicago, Illinois 60611
United States
Phone: (773) 555-0123
Date of Birth: 05/12/2008
Insurance Information:
Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Group Number: GRP-CHI-5544
Subscriber Name: Robert J. Thompson
Relationship: Child
| Date of Service | CDT Code | Description of Orthodontic Service | Fee | Amount Due |
|---|---|---|---|---|
| 09/15/2023 | D8010 | Orthodontic consultation and comprehensive diagnostic records including panoramic radiograph and cephalometric analysis performed in our Chicago clinic. | $250.00 | $250.00 |
| 09/22/2023 | D8050 | Orthodontic treatment with fixed appliances (braces). Initial placement of brackets and archwires on the maxillary arch. This procedure is part of the comprehensive alignment plan. | $4,500.00 | $4,500.00 |
| 10/06/2023 | D8050 | Orthodontic treatment with fixed appliances (braces). Initial placement of brackets and archwires on the mandibular arch. Completion of full mouth appliance placement. | $4,500.00 | $4,500.00 |
| 10/20/2023 | D8055 | Orthodontic adjustment of fixed appliances. Routine check-up and wire change to ensure proper tooth movement and alignment progress. | $150.00 | $150.00 |
| 10/20/2023 | D8056 | Orthodontic adjustment of fixed appliances. Replacement of elastic ligatures and power chains to optimize force distribution. | $100.00 | $100.00 |
| 10/20/2023 | D8058 | Orthodontic adjustment of fixed appliances. Bonding of auxiliary components including power hooks for elastics attachment. | $75.00 | $75.00 |
| 10/20/2023 | D8059 | Orthodontic adjustment of fixed appliances. Replacement of broken bracket on tooth #21 due to accidental trauma. | $125.00 | $125.00 |
| 10/20/2023 | D8060 | Orthodontic adjustment of fixed appliances. Adjustment of archwire to correct minor rotation on anterior teeth. | $100.00 | $100.00 |
Payment Terms and Important Information:
Thank you for choosing Chicago Elite Orthodontics for your orthodontic care. This invoice reflects the services rendered during the specified period. Please note that all payments are expected within 30 days of the invoice date to avoid late fees. We accept payments via credit card, debit card, check, or bank transfer. For bank transfers, please contact our billing department for account details.
Insurance claims have been submitted on your behalf. However, the patient is ultimately responsible for any balances not covered by insurance. Please verify your benefits with your insurance provider. If you have any questions regarding this invoice or your treatment plan, please do not hesitate to contact us at (312) 555-0199.
Our office is located in the heart of Chicago, Illinois, United States, and we are committed to providing the highest quality orthodontic care. We look forward to continuing your journey to a beautiful smile.
Authorized Signature:
Dr. Emily R. Carter, DDS, MS
Lead Orthodontist
Patient/Guardian Signature:
___________________________
Date: _________________
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