| Invoice Number: | 138355 |
| Billing Period: | 01/01/2007 - 01/31/2007 |
| Dental Group Number: | 20883-000-00000-28011 |
| Group Name: | FULLY INSURED |
| Master Number: | 00000 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| FULLY INSURED |
| 100 MAIN STREET |
| ANYWHERE, USA 55555-0000 |
| SUBSCRIBER ADJUSTMENTS |
|---|
The following changes have been made to our eligibility records.
*Action Code: 1=Addition, 2=Termination, 3=Eff Date Change, 4=Cov Type Change |
| Member Number | Member Last Name | Member First Name | Coverage Type | Effective Date | *Action Code | Amount Due |
|---|
| 333456789 | STONE | KERWIN | Single | 07/01/2005 | 1 | $ | 19.42 | |
| 888888888 | THOMPSON | EDWARD | S+Family | 07/01/2005 | 1 | $ | 62.26 | |
| 999999999 | VANG | DAO | Single | 07/01/2005 | 4 | $ | 19.42 | |
| 101010101 | VAUGN | DIANE | S+Family | 07/01/2005 | 1 | $ | 62.26 | |
| |
| | | | | Total Adjustments: | $ | 163.36 | |
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