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A dental receipt documents payment for professional oral health services such as cleanings, fillings, extractions, crowns, orthodontics, or cosmetic procedures. Patients typically need a copy for insurance reimbursement, FSA or HSA claims, tax deductions, or personal records. People recreate dental receipts when the original is lost, when a provider uses outdated systems, or when a detailed itemized copy is needed for an insurer.
| Section | Details |
|---|---|
| Section | Details |
| Provider Info | Dentist or practice name, address, phone number, NPI number |
| Patient Info | Patient full name, date of birth, patient or account ID |
| Date of Service | Appointment date and time of treatment |
| Procedure Codes | ADA/CDT procedure codes (e.g., D0120 for periodic exam, D2140 for amalgam filling) |
| Procedure Description | Plain-language description of each service performed |
| Fee Per Service | Standard charge for each individual procedure |
| Insurance Adjustment | Amount covered by insurance or discount applied |
| Patient Balance | Amount paid out of pocket, payment method, and date paid |
| Provider Signature | Dentist name, license number, and practice tax ID (EIN) |