Dental Insurance Claim
Dental Insurance Claim
Patient Information
Patient Name: [Your Name]
Patient ID: 123456789
Date of Birth: January 1, 2050
Insurance Policy Number: ABCD123456
Insurance Provider: Bright Dental Insurance
Provider Information
Dental Provider: Dr. Jane Smith
Provider ID: D12345
Practice Name: Smile Bright Dental Clinic
Contact Number: (555) 123-4567
Address: 123 Smile Lane, Happy Town, HT 54321
Treatment Details
|
Treatment Date |
Treatment Description |
Service Code |
Cost |
|---|---|---|---|
|
September 20, 2050 |
Comprehensive Oral Evaluation |
D0150 |
$120 |
|
September 20, 2050 |
Prophylaxis - Adult Teeth Cleaning |
D1110 |
$85 |
|
September 23, 2050 |
Filling - One Surface, Composite |
D2330 |
$150 |
|
September 25, 2050 |
Panoramic Film X-ray |
D0330 |
$120 |
Total Cost: $475
Payment Information
Amount Paid by Patient: $95
Amount Covered by Insurance: $380
Patient Acknowledgment
I hereby certify that the information provided is accurate and complete to the best of my knowledge. I authorize the release of any necessary information to process this claim and agree to pay any balance not covered by my insurance.
[YOUR NAME]
[DATE SIGNED]
