Invoice Number: | 142658 |
Billing Period: | 01/01/2007 - 01/31/2007 |
Vision Group Number: | 40001-000-00000-00000 |
Group Name: | VISION |
Master Number: | 40001 |
Description: | |
Phone Number: | (999) 999-0000 |
VISION |
GILLIAN MYER |
VP SECRETARY |
2245 BLUE JAY WAY |
ANYWHERE, USA 55555-0000 |
STATEMENT OF ACCOUNT |
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Billing Period: 01/01/2007 - 01/31/2007 Due Date: 01/01/2007
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Prior Due |
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| Prior Amount Due | $ | 62.20 | |
| Less Payment Received | | 62.20 | |
| Balance From Prior Billing | | .00 | |
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Current Due |
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| Total Subscriber Adjustments | $ | 9.72 | |
| Current Billed | | 62.20 | |
| Balance From Current Billing | | 71.92 | |
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Total Amount Due |
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| Total Amount Due | $ | 71.92 | |
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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.
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Group Name: | VISION |
Vision Group Number: | 40001-000-00000-00000 |
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Vision Amount Due: | $ 71.92 |
Vision Amount Submitted: | $ ______________________________________ |
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Signature: | |
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Please send all remittance to:
DELTA DENTAL
PO BOX 999
ANYWHERE USA 55555