Free Dental Invoice Template

This template is for a dental practice billing whoever pays for a visit. It lists the visit as a plain line with its fee, takes off anything paid at the visit and shows the amount due.

It is an invoice, not an insurance claim form. A dental plan is billed through its own claim process. The ADA Dental Claim Form, which the American Dental Association describes as "a common format for reporting dental services to a patient's dental benefit plan", is one example; a plan may also take claims electronically. This invoice tells whoever pays what they owe.

The dental invoice has:

• Dental practice: practice name, address, phone or email, and the dentist.
• Invoice details: invoice number and date, payment terms, due date and account number.
• Bill to: the name, address and phone or email of the person paying.
• Visit: the visit date.
• Services: the visit as a plain line, with the date, a plain description, the quantity, the fee and the amount.
• Totals: subtotal, total, "Less: payment received at visit" and the amount due.
• How to pay: accepted methods, placeholders for your account name and bank details, and the payment reference to quote.
• About this invoice: a note that the amount due is what remains after the payment made at the visit.
• A footnote saying the invoice shows charges only, is not an insurance claim form and contains no clinical information.

It comes as three files:

• PDF: a blank form to print and fill in by hand.
• Word (.docx) and Excel (.xlsx): the same layout filled with sample values. Overwrite them with your own. In the Excel file, each line's amount (quantity × fee), the subtotal, the total and the amount due are formulas. The amount due is the total less the payment received at the visit, which you type in. If it doesn't apply, set it to 0.00 rather than deleting the row, because the amount due refers to it. In the Word file you can simply delete lines you don't need.

The sample is one visit. Its fees only show how the form works. They are not typical fees. Use your practice's own fee schedule.

Give the visit its own line with its date, in plain words such as "Dental visit", with the quantity and fee (quantity × fee = amount).

Leave treatment, diagnoses, findings, medications and procedure codes off. They belong in the patient's record, not on a bill that may be emailed, forwarded or filed with household papers, and the template has no fields for them.

If a patient wants to claim from their dental plan themselves, ask them what their plan needs and provide it separately. Don't turn this invoice into a claim.

Payment terms. If the patient pays in full at the visit, a receipt is enough. If you invoice, print the terms and an actual due date (the sample says Net 30 and gives the date), and ask the payer to quote the reference when they pay. Billed's guide to invoice payment terms explains the common options.

Payment plans. Whether you offer one, and on what terms, is your practice's policy. If you agree on a plan with a patient, put it in writing before treatment starts: the total, the number and amount of installments and their dates. Invoice each installment as it falls due and record each payment against the account. Billed's guide to handling partial payments covers how to track them.

Deposits. If your policy is to take a deposit before longer treatment, a deposit invoice is the document for that, and the deposit is then taken off the final bill.

Patient financing. If a patient pays through a third-party financing company, their agreement is with that company, on its terms. Record what the financing company pays you as a payment on the account, and don't invoice the patient for that amount again.

Late fees. Charge them only if the patient agreed to them in advance and the rules where you practice allow it. Check your state or local rules before setting a rate. The late fee calculator can help you work out the amount.

Sales tax. The template has no sales tax line. If you sell anything that may be taxable where you practice, check your state's rules before you add one.

Whether HIPAA applies to your practice depends on what you do. CMS says health care providers who submit HIPAA transactions, like claims, electronically are covered. An invoice template can't make a practice compliant with any privacy law. Billed is not HIPAA-compliant. Whatever rules apply to you, keep clinical details off the invoice and send it only to the person responsible for paying.