Sample letter to collect patient balance due 30 days
After sending a statement indicating the balance still due on the patient’s account
Date
Patient Name
Street Address
City, State Zip
Dear (insert patient’s first name),
Thank you for your recent office visit. Our office has received payment from your dental benefit
carrier for your dental treatment. However, due to the limitations of your dental plan, only a
portion of the bill was covered. The balance of your payment is (amount). According to the
agreement you signed before you began treatment, you are responsible for this remaining
balance.
Please send this amount to our office as soon as possible. If you have any questions, contact
your dental plan carrier, your human resources department or our office at (office number).
Again, it is our pleasure to provide you with outstanding dental care.
Sincerely,
Dentist’s Signature
Content courtesy of The ADA Practical Guide to Dental Letters: Write, Blog and Email Your Way to
Success and The ADA Guidelines for Practice Success
TM
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© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any
other use, duplication or distribution by any other party requires the prior written approval of the American
Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy
applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified
lawyer or professional for legal or professional advice.
