Policies & Forms
Learn about the policies that help us provide you with the very best of care.
Office Forms & Downloads
New Patient Forms
- Please complete the forms below in preparation for your first visit.
- New Family RegistrationComplete this form once for each family or household. You will need your insurance card(s) and the subscriber's photo ID.
- New Patient RegistrationComplete this form once for each new patient.
- Policies and Procedures
Individual Forms
- These forms are included in the New Patient and Family Registration packets, and are available here for individual use.
- Authorization for Other Caregivers
- Family Medical History
- Insurance
- Notice of Privacy Practices
- Patient Portal
- Policies and Procedures
- Release Medical Records TO Bloom PediatricsRelease medical records to Bloom Pediatrics from another provider.
- Release Medical Records FROM Bloom PediatricsRelease your Bloom Pediatrics medical records to another provider.
School Forms
Patient Education Handouts
- Browse this library of expert advice from the American Academy of Pediatrics. This collection of over 800 handouts covers 200 topics ranging from Acne to Whooping Cough.
- AAP Parent Education Library
Policy Documents
Billing & Insurance
Please bring a copy of your insurance card to every visit. A scanned copy of the assigned account holder’s current insurance card and driver’s license is required to be kept on file and may be requested at the time of visit check-in. Please present newly issued insurance cards upon check-in at the next scheduled visit.
As a convenience to our patients, Bloom will file claims to any insurance carrier with whom we are a participating provider.
Accepted Insurance Plans
- We accept most insurances, including the following Medicaid HMOs and straight Medicaid:
- BCN Focus/Select Plan
- Blue Cross Complete
- Meridian Healthcare
- Molina
- United Healthcare Community Plan(Formerly Great Lakes Health Plan)
Excluded Insurance Plans
- We do not accept the following plans:
- HAP Henry Ford(Unless open network)
- Meridian Choice
- Meridian PPO
- Midwest Health Plan
- Priority Health St. John Network
- Total Health Care
If you have an HMO insurance plan, please assign one of the physicians in our practice as your child’s primary care physician prior to your visit. Failure to do so may result in the need to reschedule the appointment. Any charges not covered due to incorrect primary care physician designation are the responsibility of the assigned account holder.
It is the responsibility of the assigned account holder to understand the benefits of the policy including but not limited to, co-pay amount, co-insurance percentage and deducible amount. We are here to assist you in any way, but every policy is different and unique.
Newborns
Please contact your insurance carrier to add your newborn to an insurance policy. Most policies require the newborn to be added to the insurance policy by one month of age in order for all services to be paid from the date of birth. Failure to do so may result in a personal balance that is the financial responsibility of the assigned account holder. The newborn is considered to be under mother’s insurance and charged the designated co-pay from date of first visit until their own insurance is active. Please contact the office as soon as the baby is active on insurance so the services can be submitted for timely filing and ensure reimbursement from time of birth.
Change of Insurance or Account Information
Please notify the office as soon as possible of any and all account changes, including co-pay amounts, insurance updates, and change of mailing address. If the account holder does not notify the office within 15 calendar days of these changes, the assigned account holder becomes responsible for any and all charges.
Billing Inquiries
Questions about a bill should be directed to our External Billing Department, PedsOne at 1-866-371-6118.
Payment
Payment, in full is due at time of service. This includes applicable co-insurance, co-payments, and payments for services not covered or denied by the insurance company. Bloom Pediatrics accepts cash, personal check, debit cards, Visa, Mastercard, Discover, and American Express.
Credit Card on File
Bloom Pediatrics requires that a current credit card be kept on file for patient accounts. Please provide your credit card to the front office staff at your next visit to be linked to your account. We have software that securely encrypts and stores your credit card information displaying a token number in place of your credit card number. The credit card on file allows Bloom Pediatrics to run your card after all insurances have been processed, you have received a statement and a balance becomes past due.
Self-Pay Accounts
If you do not have insurance, please come prepared to pay for your visit in full upon check-out. A price list of services will be provided at check-in.
Missed Co-Pays
Bloom Pediatrics is required by our insurance contracts to collect all co-pays at the time of service. Failure to collect co-pays puts the responsible party and Bloom Pediatrics in default of the insurance contract. A $25 service fee will be charged in addition to your co-payment if the co-payment is not paid by the end of that business day. Multiple missed co-pays, per family, within a twelve-month period may result in dismissal from the practice.
Why do we vaccinate? Vaccines save lives.
At Bloom Pediatrics, we believe that all children should receive the recommended vaccines according to the guidelines provided by the American Academy of Pediatrics (AAP). Vaccines are safe and effective in preventing diseases and health complications in children and young adults. Regular vaccinations help children ward off infections, and are administered as one of the safest and best methods of disease prevention.
Did You Know?
- HPV causes 70% of oropharyngeal cancers in the United States.
- About 1 in 1000 children who get measles will die of measle encephalopathy 2-10 years after getting the disease.
- Even when the flu vaccine is not a good match, it can decrease the risk of hospitalization by 60-70%.
- 10-14% of people who get the meningococcal disease will die.
- There are existing vaccines that could stop rotavirus and pneumonia — two conditions that kill nearly 3 million children under the age of five every year.
We Are a Vaccinating Practice
Bloom Pediatrics requires that all of our patients are immunized according to the current vaccine schedule recommended by the American Academy of Pediatrics. All potential new patients must be up-to-date with their vaccines. We do not accept new families that do not vaccinate their children.
Immunization Resources
- For information about these vaccines, the diseases they protect against, immunization schedules, vaccine safety and other important information please visit these pages from the AAP.
- Vaccine Information Statements
- Vaccine Safety: The Facts
- Immunization Schedules
- Immunizations (AAP)
Frequently Asked Questions About Vaccines
Do vaccines contain harmful ingredients?
Vaccines contain ingredients that allow the product to be safely administered. Too much of anything can be harmful to your body, even water or oxygen. Ingredients, such as formaldehyde, thiomersal and aluminum, are found in higher quantities naturally in our environment.
Infants receive 4.4 milligrams of aluminum in the first six months of life and breast-fed infants ingest about 7 milligrams, formula-fed infants ingest about 38 milligrams, and infants who are fed soy formula ingest almost 117 milligrams of aluminum during the first six months of life.
Each vaccine contains less than 0.1mg of formaldehyde.
Formaldehyde is essential in human metabolism and is required for the synthesis of DNA and amino acids (the building blocks of protein). Therefore, all humans have detectable quantities of natural formaldehyde in their circulation (about 2.5 ug of formaldehyde per ml of blood). Assuming an average weight of a 2-month-old of 5 kg and an average blood volume of 85 ml per kg, the total quantity of formaldehyde found in an infant’s circulation would be about 1.1 mg, a value about 1,500 times more than the amount an infant would be exposed to in any individual vaccine.
Thimerosal contains a different form of mercury called ethylmercury. Studies comparing ethylmercury and methylmercury suggest that they are processed differently in the human body. Ethylmercury is broken down and excreted much more rapidly than methylmercury. Therefore, ethylmercury (the type of mercury in the influenza vaccine) is much less likely than methylmercury (the type of mercury in the environment) to accumulate in the body and cause harm. We consume more Methylmercury from fish.
Do vaccines cause autism or sudden infant death syndrome?
The study that linked autism and vaccines in 1998 was retracted because it was significantly flawed by bad science. Since then, there have been over 300 independent studies disproving the link. There has been no shown link between vaccines and SIDS as well.
Is it better to develop a natural immunity to the disease, or to take a vaccine to prevent the disease?
Immunizations were developed to prevent complications from diseases. For example:
- During an average flu season, 36,000 Americans die and more than 200,000 are hospitalized because of complications from influenza. 20,o00 children are hospitalized each year due to influenza.
- For every 1,000 children who get measles, 1-2 of them will die.
- 1 in 10 people who get meningococcal disease dies of it.
Vaccines stimulate the immune system to produce an immune response similar to natural infection, but they do not cause the disease or put the immunized person at risk of its potential complications.
Can you get the disease from the vaccine?
Most vaccines are inactive vaccines. This means they are not live and cannot spread the disease at all. Think of it as just a fingerprint of the disease so that the body knows what to fight against when exposed.
A few vaccines contain the live vaccines that can lead to a milder case of the disease. Live vaccines include MMR, Chickenpox, Rotavirus and FluMist. For example, the chickenpox vaccine can cause a mild chickenpox rash around the site of the vaccine. This isn’t harmful and actually shows that the vaccine is doing its job.
Why do babies get so many vaccines? Can they handle them?
Babies have not developed immunity to most diseases. For this reason, they are at increased risk of becoming infected and getting seriously ill by diseases. Vaccinations protect babies by building up their natural defenses.
When a baby is first born, they are exposed to thousands of different germs. Vaccines only use a small amount of antigens to help babies boost their immune system. The antigens are what helps the body identify and fight the disease.
Vaccination Schedule
Office Policies & Procedures
Patient Privacy
Bloom Pediatrics providers and staff are governed by and comply with the federal Health Insurance Portability and Accountability Act (HIPAA). We must abide by the terms of our office Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain. A copy of our current HIPAA statement is available upon request. Patients aged 18 and older must sign a waiver authorizing parental access to their account. Parents of patients over 18 will not be permitted to access any medical or billing information without written consent from the patient.
Missed Appointments and Late Arrivals
Missed appointments represent a cost to us, you, and to other patients that could have been seen during the time set aside for your child. Cancellations are required 24 hours prior to any well visit appointment and two hours prior to any sick visit appointment via phone call to the practice. A “No Show” fee of $50 will be applied if an appointment is missed and not cancelled within the stated timeframe.
If you are 10 (or more) minutes late for appointment, it will need to be rescheduled.
Records Requests
If you wish to obtain a copy of your medical records you must complete the authorization to release records form, which can be obtained by calling the office or at www.bloompediatricsmi.com.
The form needs to be completed in its entirety to process the request. Records will be mailed to the assigned account holder or available for pick up at the office within 5 business days of the request. A signed records release and payment of $20 must be received for a copy of the patient’s full medical record prior to completing the request. A summary of care can be provided at no cost. All outstanding balances must be paid before records are transferred.
Health Appraisal/Sports Physical Forms
A health appraisal or sports form will be generated during every well visit. Upon completion, the form will be added to the patient portal and made available in the portal documents for your convenience. If you require a health appraisal or sports form outside of a well visit and have had a well visit with a Bloom Pediatrics provider within the last year, you may request one by filling out the appropriate form’s first page. This portion is required to be completed by a parent or guardian (or patient over 18) before a doctor will sign and return it to the patient portal. Forms requested outside of a well visit require three business days for completion.
Referrals
Some insurances may require a referral by our office to see a specialist. Please refer to the list of recommended specialists given to you during your visit. If you did not receive a list, one can be requested by calling the office. Once you have scheduled the specialist appointment, please call Bloom Pediatrics with the date, time, and name of the specialist with whom you have an upcoming appointment, and your referral will be completed within 5 business days.
Medication Refills and Prior Authorizations
If you are in need of a medication refill or require a prior authorization for a medication, please log into the patient portal and send us a message. Medication refills may require an associated medication refill or medication re-check visit. Prescriptions will be sent to the preferred pharmacy on file with the office unless otherwise requested by the assigned account holder.
After-Hours Care
If your child’s illness or injury is life-threatening, call 911.
Otherwise, for urgent matters that cannot wait until business hours, call (928) 356-0006 to be connected to a pediatric-trained triage nurse. Please keep in mind we are open until 8 pm Monday through Friday and until 1pm on Saturday and Sunday. Please call for an appointment.
Bloom Pediatrics does not endorse minute clinic visits for acute care or sports physicals.
Bloom Pediatrics does not endorse vaccination at national drug store chains and believes your child’s medical home is the best place for all preventative care! Come see us!
Urgent Care
Corewell Health Beaumont Troy Hospital Children’s After Hours Clinic
44201 Dequindre Road
Troy, MI 48085
Mon – Fri
6:00 am – 10:00 pm
Sat–Sun
11:00 am – 9:00 pm
Thanksgiving Day, Christmas Day and New Year’s Day
11:00 am – 9:00 pm
Emergency Care
Corewell Health Stuart H. Blanck Emergency – William Beaumont University Hospital
3601 W. 13 Mile Road
Royal Oak, MI 48073
Corewell Health Beaumont – Troy Hospital Emergency
44201 Dequindre Road
Troy, MI 48085
Children’s Hospital of Michigan – Troy Emergency Room
350 W. Big Beaver Road
Troy, MI 48084
Children’s Hospital of Michigan – Detroit Emergency Room
3901 Beaubien
Detroit, MI 48201
