UCSF Dental Center Billing Statement

Questions about your bill?

Our billing statement reference guide will help you understand the components of your bill.

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The UCSF Dental Center billing statement is designed to make it easy for you to keep track of services you have received and payments made to your account. To understand what each element of the billing statement represents, please see our reference guide (pictured below). If you have additional questions or need to speak to a billing representative about a specific item on your bill, please call the number listed in the “Contact Us” section on page 1 of your statement.

DC statement page 1

1 STATEMENT DATE: The date the statement was created.
2 PATIENT NAME: The person or party who is financially responsible for all the accounts on the statement.
3 ACCOUNT NUMBER: Your account and chart#.
4 PAYMENT DUE DATE: The date that payment is due.
5 PRIOR STATEMENT DATE: The date of your last statement.
6 CURRENT BALANCE: The total amount owed by the patient as of the statement date.
7 AMOUNT DUE NOW: The amount owed for this statement.
8 UNDELIVERABLE MAIL:  This address is used for undeliverable mail only.  Please do not send correspondence or payments to this address.  
9 A MESSAGE FOR YOU: We will display your next two appointments for the Dental Center, if any.  This section will also populate specific account information and alerts when needed.
10 QUESTIONS: See various ways to contact UCSF Dental Center Patient Billing Services.  
11 PAYMENT OPTIONS: This section advises on the various payment options available. You can also scan the QR code in this section with your smartphone to make a payment.
12 RETURN PAYMENT COUPON: Use this coupon to mail in a credit card or check payment.  NOTE: The reverse side of the coupon provides the ability to make changes to address or insurance information.

UCSF Dental Center Statement 2nd page
13 PRACTICE: Identifies the UCSF Dental Center Practice where the services were provided.
14 PROVIDER: Identifies the Authorizing Provider for the services performed.
15 DATE: The date of service.
16 CODE: The billing code used to identify the service.
17 CHARGE DESCRIPTION:  The description of the service.
18 CHARGE AMOUNT: The amount charged for the service.  
19 INSURANCE PAYMENT: The insurance payments received on this account.
20 INSURANCE ADJUSTMENT: Insurance adjustments posted to this account.
21 PATIENT ADJUSTMENTS: Patient adjustments posted to this account.
22 PATIENT PAYMENT: Patient payment posted to this account.
23 PATIENT LIABILITY: The patient liability amount remaining on this account.
24 TOTAL AMOUNT OWED THIS STATEMENT: The sum total of all patient liability amounts on this statement.
25 COVERAGE ON ACCOUNT: Displays the insurance coverage(s) that UCSF Dental Center has on file for the patient on this statement.