Invoice Orthodontist in United States Los Angeles –Free Word Template Download with AI
Dr. Elena Rodriguez, DDS, MS
Board Certified Orthodontist
1234 Wilshire Boulevard, Suite 500
Los Angeles, CA 90017
United States
Phone: (213) 555-0199
Email: [email protected]
Tax ID: 94-1234567
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: Michael James Anderson
Guardian: Sarah Anderson
456 Sunset Boulevard, Apt 12B
Los Angeles, CA 90028
United States
Phone: (323) 555-0144
Date of Birth: 05/12/2010
Insurance Information:
Provider: Blue Cross Blue Shield of California
Policy Number: BCBS-99887766
Group Number: GRP-CA-5544
Subscriber ID: SUB-112233
Relationship: Child
| Date | CPT Code | Description of Orthodontic Services | Fee | Adj. | Balance |
|---|---|---|---|---|---|
| 09/15/2023 | D8010 | Comprehensive Orthodontic Consultation: Initial examination, diagnostic records, and treatment planning for patient residing in Los Angeles, CA. | $250.00 | -$150.00 | $100.00 |
| 09/15/2023 | D0330 | Panoramic Radiograph: Full mouth X-ray required for orthodontic assessment. | $180.00 | -$100.00 | $80.00 |
| 09/20/2023 | D8050 | Orthodontic Treatment with Fixed Appliances (Braces): Initiation of comprehensive treatment plan. Includes placement of brackets and archwires. | $4,500.00 | -$2,000.00 | $2,500.00 |
| 10/18/2023 | D8055 | Orthodontic Treatment with Fixed Appliances: Monthly adjustment visit. Wire change and ligature replacement. | $150.00 | $0.00 | $150.00 |
| 10/18/2023 | D8060 | Orthodontic Treatment with Fixed Appliances: Emergency visit for bracket repair and rebonding. | $100.00 | $0.00 | $100.00 |
| Subtotal: | $5,180.00 |
| Insurance Adjustment: | -$2,250.00 |
| Previous Payments: | -$1,000.00 |
| Total Due: | $1,930.00 |
Payment Terms and Important Information
Payment Methods: We accept Visa, MasterCard, American Express, Discover, Cash, and Personal Checks. For online payments, please visit our secure portal at www.smilealignla.com/pay.
Due Date: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge as permitted by California state law.
Insurance: This invoice reflects the estimated insurance adjustments based on your Blue Cross Blue Shield of California plan. Final adjustments may vary slightly upon claim adjudication. Please contact our billing department if you have questions regarding your coverage.
Financing: We offer flexible financing options through CareCredit for orthodontic treatments in Los Angeles. Please inquire at the front desk for details.
Disputes: If you believe there is an error on this invoice, please contact us within 10 days of receipt. Please reference Invoice Number INV-2023-8842 in all correspondence.
Location: All services were rendered at our Los Angeles, CA office. Please ensure your address is up to date for future correspondence.
Authorized By:
Dr. Elena Rodriguez, DDS, MSPatient/Guardian Signature:
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