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| We are sorry that you
have to leave our practice. We have enjoyed the time you have spent with us and
wish you the best in this new chapter of your life. Please let us know if there
is anything we can do to help in your transition to another orthodontist for
further treatment. Below you will find a standard calculation of fees for
treatment in progress. You will also find the total amount of payments received
by our office from you or your insurance company.
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| PatientName: Doe,
Cookie |
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Responsible Party Name: Doe,
Cookie |
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| Estimated Treatment Time: |
18 |
Original Treatment Fee: |
$4,288.00 |
| Start of Treatment Date: |
1/12/2007 |
| Transfer Out Date: |
1/19/2007 |
Separate Fee Components |
|
| Completed Months of Treatment: |
0 |
Banding Fee: |
$1,501.00 |
| First Half Treatment Completed: |
0.00% |
First Half of Treatment Fee: |
$1,672.00 |
| Second Half Treatment Completed: |
0.00% |
2nd Half of Treatment Fee: |
$1,115.00 |
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| Paid To Date |
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Transfer Out Case Fee |
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| Insurance Paid: |
$0.00 |
Banding Fee: |
$1,501.00 |
| Patient Paid: |
$0.00 |
Prorated First Half Treatment Fee: |
$0.00 |
| Total: |
$0.00 |
Prorated Second Half Treatment Fee: |
$0.00 |
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Total: |
$1,501.00 |
| Transfer Case Fee: |
$1,501.00 |
| Retainer / Brace Removal Credit: |
$0.00 |
| Paid To Date : |
$0.00 |
| Balance Due: |
$1,501.00 |
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