Invoice Orthodontist in United States New York City –Free Word Template Download with AI

Bill To (Patient/Guardian)

Mr. Johnathan Doe

456 West 14th Street
New York, NY 10011
United States

Phone: (917) 555-0123
Email: [email protected]

Patient Information

Patient Name: Emily Doe

Date of Birth: 05/12/2010

Policy Number: AETNA-99887766

Insurance Provider: Aetna Dental PPO

Description of Orthodontic Services Rendered

The following invoice details the professional orthodontic services provided by Manhattan Elite Orthodontics in accordance with the treatment plan approved for the patient. All procedures were performed in our New York City facility by licensed orthodontic specialists.

Date	Code	Description of Service	Fee	Insurance Est.
10/01/2023	D8010	Orthodontic Consultation & Diagnostic Records (X-rays, Impressions)	$350.00	$175.00
10/15/2023	D8050	Placement of Fixed Orthodontic Appliances (Braces) - Full Mouth	$5,500.00	$2,750.00
10/20/2023	D8055	Adjustment of Fixed Orthodontic Appliances	$150.00	$75.00
10/22/2023	D8070	Emergency Orthodontic Visit (Broken Bracket Repair)	$100.00	$50.00
10/24/2023	D8075	Removal of Fixed Orthodontic Appliances (Retainer Phase Initiation)	$200.00	$100.00

Subtotal: $6,300.00 Estimated Insurance Payment: -$3,150.00 Patient Responsibility (Co-pay/Deductible): $3,150.00 Less: Previous Payments: -$1,500.00 Total Amount Due: $1,650.00 Payment Instructions

We accept the following forms of payment for this invoice:

Credit/Debit Card: Visa, MasterCard, American Express (3% processing fee applies)
Check: Payable to "Manhattan Elite Orthodontics"
Bank Transfer: Please contact our billing department for ACH details
Payment Plan: Available for balances over $1,000. Contact us to arrange.

Online Payment: Visit www.manhattaneliteortho.com/pay and enter Invoice #INV-2023-10-458.

Important Notes & Terms

1. Insurance Verification: The estimated insurance payments listed are based on pre-authorization estimates. Actual payments may vary. Please submit this invoice to your insurance provider if required.

2. Payment Deadline: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge.

3. Disputes: If you have any questions or disputes regarding this invoice, please contact our billing department at (212) 555-0199 within 10 business days.

4. Privacy: This document contains protected health information (PHI) under HIPAA regulations. Please handle with confidentiality.

5. New York City Regulations: This invoice complies with all applicable New York State and New York City dental practice regulations.

Authorized Signature

Dr. Sarah Johnson, DDS, MS
Lead Orthodontist

Patient/Guardian Signature

Acknowledging receipt and responsibility

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