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]
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