Invoice Orthodontist in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, FL 33131, United States
Phone: (305) 555-0199 | Fax: (305) 555-0198
Email: [email protected]
NPI: 1234567890 | FL License: #12345
Invoice #: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Location: Miami, FL
BILL TO:
Patient Name: Maria Elena Rodriguez
Address: 4500 SW 8th Street
Miami, FL 33134, United States
Phone: (786) 555-0123
Date of Birth: 05/12/2010
PAYMENT FROM / INSURANCE:
Primary Insurer: Blue Cross Blue Shield of Florida
Policy Holder: Carlos Rodriguez
Policy Number: BCBS-FL-99887766
Group Number: GRP-445566
PCP: Dr. James Wilson, MD
| # | Date of Service | Description of Orthodontic Services | CDT Code | Fee | Amount Due |
|---|---|---|---|---|---|
| 1 | Oct 24, 2023 | Initial Comprehensive Orthodontic Consultation and Diagnostic Records (X-rays, photos, models) in Miami. | D0450 | $250.00 | $250.00 |
| 2 | Oct 24, 2023 | Orthodontic Treatment with Fixed Appliances (Braces) - Upper Arch. Includes brackets, bands, and archwires. | D8050 | $4,500.00 | $4,500.00 |
| 3 | Oct 24, 2023 | Orthodontic Treatment with Fixed Appliances (Braces) - Lower Arch. Includes brackets, bands, and archwires. | D8050 | $4,500.00 | $4,500.00 |
| 4 | Oct 24, 2023 | Interceptive Orthodontic Treatment - Space Maintainer (if applicable for future alignment). | D8060 | $350.00 | $350.00 |
| 5 | Oct 24, 2023 | Orthodontic Retainer - Fixed (Bonded) for Upper Arch post-treatment stability. | D8070 | $400.00 | $400.00 |
| 6 | Oct 24, 2023 | Orthodontic Retainer - Fixed (Bonded) for Lower Arch post-treatment stability. | D8070 | $400.00 | $400.00 |
| 7 | Oct 24, 2023 | Emergency Orthodontic Visit - Adjustment of loose bracket or wire irritation. | D8090 | $150.00 | $150.00 |
| 8 | Oct 24, 2023 | Professional Fee for Orthodontic Supervision and Monthly Adjustments (Initial Deposit). | D8095 | $1,000.00 | $1,000.00 |
Payment Terms & Important Information for Miami Patients:
Thank you for choosing Miami Elite Orthodontics for your orthodontic care in the United States. This invoice reflects the professional fees for orthodontic services rendered. Payment is due within 30 days of the invoice date. We accept major credit cards, HSA/FSA cards, cash, and checks.
Insurance: We have submitted a claim to your primary insurance provider. The amount shown as "Insurance Estimate" is an anticipated benefit based on your plan details. Final coverage may vary. You are responsible for any difference between our fees and the insurance payment.
Payment Plans: We offer flexible financing options through CareCredit and in-house payment plans for residents of Miami-Dade County. Please contact our billing department to discuss monthly payment arrangements.
Late Fees: A late fee of 1.5% per month will be applied to any balance remaining unpaid after the due date.
Contact: For questions regarding this invoice or your orthodontic treatment plan, please call our Miami office at (305) 555-0199 or email [email protected].
Authorized Signature:
Dr. Sofia Martinez, DDS, MS
Lead Orthodontist
Miami Elite Orthodontics
Patient/Guardian Signature:
___________________________
Date: _____________________
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