Invoice Orthodontist in United States Houston –Free Word Template Download with AI
1200 Smith Street, Suite 400
Houston, Texas 77002
United States
Phone: (713) 555-0199 | Fax: (713) 555-0198
Email: [email protected]
TIN: 74-1234567
Invoice Number: INV-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: September 1, 2023 - October 24, 2023
Bill To (Patient/Guardian)
Mr. Robert & Mrs. Sarah Jenkins
4500 Westheimer Road, Apt 12B
Houston, Texas 77027
United States
Phone: (281) 555-0144
Patient Name: Emily Jenkins (DOB: 05/12/2010)
Insurance Information
Provider: Blue Cross Blue Shield of Texas
Policy Number: BCBS-TX-99887766
Group Number: GRP-HOU-554
Subscriber ID: SUB-RJ-4432
Authorization Code: AUTH-ORTHO-2023-99
| Date | CDT Code | Description of Orthodontic Services | Fee | Insurance Est. | Patient Resp. |
|---|---|---|---|---|---|
| 09/01/2023 | D8010 | Comprehensive Orthodontic Consultation and Diagnostic Records (X-rays, Photos, Impressions). | $250.00 | $150.00 | $100.00 |
| 09/15/2023 | D8050 | Orthodontic Treatment with Fixed Appliances (Braces) - Initial Placement and Bonding. | $4,500.00 | $2,000.00 | $2,500.00 |
| 10/01/2023 | D8055 | Orthodontic Treatment with Fixed Appliances - Monthly Adjustment and Progress Check. | $150.00 | $150.00 | $0.00 |
| 10/15/2023 | D8055 | Orthodontic Treatment with Fixed Appliances - Monthly Adjustment and Progress Check. | $150.00 | $150.00 | $0.00 |
| 10/20/2023 | D8056 | Orthodontic Treatment with Fixed Appliances - Emergency Repair (Broken Bracket Replacement). | $100.00 | $50.00 | $50.00 |
| Subtotal: | $5,150.00 |
| Insurance Estimated Payment: | -$2,500.00 |
| Previous Payments Applied: | -$1,000.00 |
| Total Amount Due: | $1,650.00 |
Payment Instructions
Please remit payment for the outstanding balance of $1,650.00 by the due date listed above. Late payments may be subject to a 1.5% monthly finance charge as per our office policy.
Accepted Payment Methods:
- Check: Payable to "Houston Elite Orthodontics". Mail to the address listed in the header.
- Credit Card: Visa, MasterCard, American Express, and Discover accepted. Please call (713) 555-0199 to pay by phone securely.
- Online Payment: Visit our secure patient portal at portal.houstoneiteortho.com to pay via credit card or bank transfer.
Financing Options: We offer flexible financing plans through CareCredit and Alphaeon Credit for patients in Houston and surrounding areas. Please contact our billing department for details.
Terms and Conditions
1. Accuracy of Information: The patient/guardian is responsible for ensuring that all insurance information provided is accurate and up-to-date. Houston Elite Orthodontics is not liable for any discrepancies resulting from incorrect information.
2. Insurance Coverage: The amounts listed under "Insurance Est." are estimates based on current policy information. Actual reimbursement may vary. The patient is ultimately responsible for any balance not covered by insurance.
3. Payment Responsibility: Payment is due upon receipt of this invoice. If you have questions regarding this invoice, please contact our billing department within 10 business days.
4. Privacy Policy: In compliance with HIPAA regulations, your personal and medical information is kept strictly confidential. This invoice contains protected health information (PHI) and should be handled accordingly.
5. Service Guarantee: Houston Elite Orthodontics is committed to providing the highest quality orthodontic care in the United States. If you are not satisfied with any aspect of your treatment, please speak with Dr. Smith immediately.
6. Emergency Services: In case of orthodontic emergencies outside of regular office hours, please call our emergency line at (713) 555-0199. Additional fees may apply for after-hours appointments.
7. Retention: This invoice and related records will be retained for a minimum of seven years in accordance with Texas state law and federal regulations.
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