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April 24, 2024

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Invoice Number:140979
Billing Period:01/01/2007 - 01/31/2007

Dental Group Number:03905-000-00005-00000
Vision Group Number:40013-000-00000-00000
Group Name:FULLY INSURED JOINT-BILLED
Master Number:10302
Description: 
Phone Number:(999) 999-0000

FULLY INSURED JOINT-BILLED
JANE SINCLAIR
500 DIAMOND
ANYWHERE, USA 55555-0000

STATEMENT OF ACCOUNT
Billing Period: 01/01/2007 - 01/31/2007
Due Date: 01/01/2007

Dental Prior Due
 Prior Amount Due$3,120.84 
 Less Payment Received 3,120.84 
 Balance From Prior Billing .00 
 
Dental Current Due
 Total Subscriber Adjustments$42.84-
 Current Billed 3,119.26 
 Balance From Current Billing 3,119.26 
 
 Total Amount Due 3,076.42 
Vision Prior Due
 Prior Amount Due$268.73 
 Less Payment Received 268.73 
 Balance From Prior Billing .00 
 
Vision Current Due
 Total Subscriber Adjustments$3.01 
 Current Billed 254.52 
 Balance From Current Billing 254.52 
 
 Total Amount Due 257.53 
Grand Total Due
 Grand Total Due$3,333.95 
     

Please make checks payable to: DELTA DENTAL

Payments and changes not reflected on this invoice will appear on the next invoice.

PLEASE RETURN THIS STATEMENT OF ACCOUNT PAGE WITH YOUR PAYMENT.

 
Group Name: FULLY INSURED JOINT-BILLED
Dental Group Number:03905-000-00005-00000Vision Group Number:40013-000-00000-00000
Dental Amount Due:$ 3,076.42  Dental Amount Submitted:$ ____________________
Vision Amount Due:$ 275.53  Vision Amount Submitted:$ ____________________
Signature: 
 

Please send all remittance to:
DELTA DENTAL
PO BOX 999
ANYWHERE USA 55555