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| Current Location: | Home > Interactive Demonstration > Employer Connection > Billing Invoices > Dental ASO 2 Digit Reconciliation |
April 18, 2024
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 Customize & Download Statement (PDF) Download Eligibility Worksheet (PDF) |
| Invoice Number: | 148348 |
| Reconciliation Period: | 01/01/2007 - 01/31/2007 |
| Master Number: | 03000-00 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| SELF INSURED SUMMARY |
| BENEFITS ADMINISTRATOR |
| 321 UNIVERSITY AVENUE |
| ANYWHERE, USA 55555-0000 |
| RECONCILIATION OF ACCOUNT | ||||
|---|---|---|---|---|
| Reconciliation Period: 01/01/2007 - 01/31/2007 Due Date: 02/10/2007 | ||||
| Prior Due | ||||
| Prior Amount Due | $ | .00 | ||
| Less Deposits Received | 4,916.50 | |||
| Balance Forward | 4,916.50 | - | ||
| Current Due | ||||
| Total Administration Adjustments | $ | 8.30 | ||
| Current Administration Billed | 348.60 | |||
| Claim Payments | 4,559.60 | |||
| Balance From Current Billing | 4,916.50 | |||
| Total Amount Due | ||||
| Total Amount Due | $ | .00 | ||
Please make checks payable to: DELTA DENTAL
Payments and changes not reflected on this invoice will appear on the next invoice.
PLEASE RETURN THIS PAGE WITH YOUR PAYMENT.
Include the completed eligibility transmittal form if changes are to be made to enrollment. Retain all other documents for your records.
| Group Name: | SELF INSURED SUMMARY |
| Dental Group Number: | 03000-00 |
| Dental Amount Due: | $ .00 |
| Dental Amount Submitted: | $ ______________________________________ |
| Signature: | ______________________________________ |
Please send all remittance to:
DELTA DENTAL
ASO BILLING
PO BOX 999
ANYWHERE USA 55555