Financial Policy

Parent/Guardian First Name:*
Parent/Guardian Last Name:*
Phone Number:*
Email Address:*
As a courtesy to all of our patients, we will call to verify benefits and will make reasonable effort to collect from your insurance company, should you choose to utilize insurance. Please understand, however, primary responsibility for understanding coverage limits belongs to the parent/guardian. There are instances when insurance may deny benefits (deductible not met, services not covered under the plan, etc.) and you will then be responsible for payment. In the event that insurance denies payment, the family may wish to appeal the matter to their insurance company, and we will support the parent in their effort. Any payment which is deemed to be due from the parent (private pay/co-pays) is due at the time of the service.

If a payment plan is required, those terms will be provided to you in writing and agreed upon by both EBS Children’s Institute of Oxford and the person responsible for patient’s bills. Please inquire with our office administration regarding rates for services.
Notification of Insurance Changes/Renewal Policy

EBS Children’s Institute of Oxford (EBS) must have current information on file regarding Insurance at all times. It is the responsibility of the parent/guardian to know of any and all changes that may occur in your insurance policy. It is also the responsibility of the parent/guardian to be sure that EBS is aware of any and all changes to the policy at or before the time that they go into effect.

Please note: Many insurance policies change in January each year; however, they can change at any time.

*Notification of Change: All changes must be directed to the Clinic Administration Staff and appropriate insurance card and identification provided.

All co-pays must be PAID AT TIME OF SERVICE. We can offer to have a credit card on file for your co-pays if you prefer.

We thank you in advance for your cooperation and invite you to call the clinic at 662-380-5170 with any questions that you may have about billing.

I have read and agree to my financial responsibility for the services provided to me by EBS Children’s Institute of Oxford. This also certifies that the information I have provided to EBS Children’s Institute of Oxford, to the best of my knowledge, is true and accurate. I authorize my insurance carrier to pay EBS Children’s Institute of Oxford the full and entire amount of the bill incurred by my child.
Child's Name:
Date:
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