Get Fillable Dental Invoice 2020-2026

This guide provides step-by-step instructions for completing the Fillable Dental Invoice. Whether you are new to online forms or have experience, this comprehensive resource will help you navigate each section with ease.

Follow the steps to successfully complete your Fillable Dental Invoice

1. Click the ‘Get Form’ button to obtain the Fillable Dental Invoice and open it in your preferred online editor.
2. Begin by entering the patient’s name in the designated fields, ensuring you fill in the first name, middle initial, and last name accurately.
3. Indicate the relationship of the patient to the employee by selecting from the options provided, such as self, child, spouse, or other.
4. Select the patient’s sex from the choices of male or female.
5. Record the patient’s birth date in the format MM DD YYYY.
6. Fill in the employee or subscriber's name and mailing address accurately.
7. Input the employee's social security or identification number in the required field.
8. Provide the employee's birth date in the format MM DD YYYY.
9. If applicable, indicate whether the patient is covered by another dental plan by selecting 'yes' or 'no'.
10. If the patient is covered by another plan, complete the fields for group number and the name and address of the carrier.
11. If the patient is a full-time student, provide the name of the school they attend.
12. Enter the employer's name and address, ensuring accuracy for potential communications.
13. Document the group number associated with the patient’s insurance.
14. If applicable, provide names and addresses for any other employers.
15. Complete the authorization section by signing the document as the patient or parent if the patient is a minor.
16. Enter the name of the billing dentist or dental entity.
17. Indicate the date and sign to authorize the release of information related to the claim.
18. Fill in the address where payment should be sent, including city, state, and zip code.
19. Provide the date of the first visit or consultation.
20. Indicate the place of treatment, whether it is an office setting or elsewhere.
21. Complete any required information about prior medical placements, if applicable.
22. Input treatment details, specifying procedures and their dates.
23. Certify that the services provided have been completed and document the actual fees charged.
24. Review the entire form for accuracy and completeness before saving changes, downloading, printing, or sharing the completed invoice.

Complete your Fillable Dental Invoice online today for efficient processing.