FRIENDLY SMILES DENTAL

85 Market Street

Falmouth
CHEQUE DETAILS
GUARDIAN LIFE LIMITED - 001
Batch Id Date Claim No Member_ID Name Benefit Charged Copay Payable Fee Gct Total Reject Reason

Cheque Number: E1921616 1/10/24 12:00 AM

8599 20240106 0021322 7099-02-510278-001 TIANA BURKE DENTAL 7,000.00 1,400.00 5,600.00 98.00 14.70 5,487.30 null

8599 20240105 A021304 7099-01-511434-000 SHAKQUELLE REID DENTAL 2,500.00 0.00 2,500.00 43.75 6.56 2,449.69 null

8599 20240106 A021312 7099-01-510101-000 ANTIONETTE ANDERSON DENTAL 11,000.00 4,000.00 7,000.00 122.50 18.38 6,859.12 null

8599 20240106 A021313 7099-01-510101-000 ANTIONETTE ANDERSON DENTAL 11,000.00 11,000.00 0.00 0.00 0.00 0.00 null

8599 20240106 A021314 7099-01-510101-000 ANTIONETTE ANDERSON DENTAL 11,000.00 11,000.00 0.00 0.00 0.00 0.00 null

8599 20240106 A021315 7099-01-510101-000 ANTIONETTE ANDERSON DENTAL 11,000.00 11,000.00 0.00 0.00 0.00 0.00 null

8599 20240106 B021312 7099-03SUPP-510101- ANTIONETTE ANDERSON DENTAL 4,000.00 0.00 4,000.00 70.00 10.50 3,919.50 null

8599 20240106 B021313 7099-03SUPP-510101- ANTIONETTE ANDERSON DENTAL 11,000.00 0.00 11,000.00 192.50 28.88 10,778.62 null

8599 20240106 B021314 7099-03SUPP-510101- ANTIONETTE ANDERSON DENTAL 11,000.00 11,000.00 0.00 0.00 0.00 0.00 null

8599 20240106 B021315 7099-03SUPP-510101- ANTIONETTE ANDERSON DENTAL 11,000.00 11,000.00 0.00 0.00 0.00 0.00 null

Totals for Cheque number: E1921616 90,500.00 60,400.00 30,100.00 526.75 79.02 29,494.23

Totals for: FRIENDLY SMILES DENTAL 90,500.00 60,400.00 30,100.00 526.75 79.02 29,494.23

Received By:

Name :

Signature :

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