2024 New Family Registration

New Family Registration

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Instructions

Complete this form once for each family or household. It contains the following sections:
1. Patients
2. Release of Medical Records
3. Insurance
4. Family Demographics
5. Family Medical History
6. Policies and Procedures
7. Patient Portal
8. Notice of Privacy Practices
9. Authorization for Other Caregivers
You will need your insurance card(s) and the subscriber's photo ID.

Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?*
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name*
Patient 2 Date of Birth*

MonthDayYear
Date
Patient 3 Name*
Patient 3 Date of Birth*

MonthDayYear
Date
Patient 4 Name*
Patient 4 Date of Birth*

MonthDayYear
Date
Patient 5 Name*
Patient 5 Date of Birth*

MonthDayYear
Date
Patient 6 Name*
Patient 6 Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
How did you hear about Bloom Pediatrics?*

Release of Medical Records

To Bloom Pediatrics
Physican Releasing Records
Name*
In Newborn please enter "NA"
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Releasing Records To

Bloom Pediatrics
2055 E 14 Mile Road
Birmingham, MI 48009

Phone: (248) 645-1740
Fax: (248) 645-5304

info@bloompediatricsmi.com
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
I authorize the following to be released via fax/email/mail (check all that apply):*

All records of care between the Start and End dates noted aboveProgress notes and physical exam notes for the past 12 monthsLab testsRadiology testsImmunization recordsOther
Authorization

Signature of Patient (if 18 years or older), Parent, or Guardian
Signature*

Clear
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date

MonthDayYear
Date

Insurance
Primary Insurance
Do you have primary insurance?*

YesNo
Primary Insurance Provider*
ID Number*
Group Number*
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card, as well as the front of the subscriber's photo ID. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Subscriber's Photo ID*

Front of Driver's License or State Photo ID
Cancelof
Secondary Insurance
Do you have secondary insurance?*

YesNo
Secondary Insurance Provider*
ID Number*
Group Number*
Copay*
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
Start Date*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Subscriber's Photo ID

Front of Driver's License or State Photo ID, if different from Primary Subscriber
Cancelof
Medicaid
Have any of the patients listed above ever been on Medicaid? If so, list their name with the start and end dates:
Insurance Authorization and Assignment (Please Read and Sign)

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Family Demographics
Please list all other individuals living in the child’s home, who are not patients.
How many other individuals live in the child's home?*
Do not include any of the patients listed on the first page of this form.
Name 1*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 2*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 3*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 4*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 5*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 6*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Which languages are spoken regularly in the home?*
English
Are there pets in the home? If so, what kinds?
Are there guns in the home?*

Yes, lockedYes, unlockedNo
Is there exposure to tobacco or marijuana smoke or vapor?*

YesNo
What are the parents' occupations?*
Does your family have dietary preferences or restrictions? If so, provide details.

Policies and Procedures
Thank you for choosing Bloom Pediatrics as your child’s health care provider. The following is a copy of our practice policies and procedures. Patient care is not permitted without the written consent of receipt and acknowledgement of the understanding of this policy. This policy applies to each child within a family.
Consent to Examine and Treat a Minor

I do hereby consent and authorize Bloom Pediatrics and/or such associates, assistants or designees, to examine and treat my minor child(ren).

I affirm that I have the legal right to consent to this. This consent is binding until specifically revoked by myself or another person who has the right to sign or revoke this form.

I give the providers at Bloom Pediatrics permission to treat my child in my absence in case of emergency or when accompanied by a designated representative.
Initials*
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.
Initials*

Well Visits and Vaccines

At Bloom Pediatrics, we feel strongly about children having routine well check-ups. Per the American Academy of Pediatrics, children should receive preventative health care at the following ages:

Newborn, 3-5 days of life	6 months of age	18 months of age
1 month of age	9 months of age	24 months of age
2 months of age	12 months of age	30 months of age
4 months of age	15 months of age	3-21 years of age–on a yearly basis

We expect our parents to follow these guidelines so that we may continue to provide quality healthcare to our children. Failure to do so may result in dismissal from the practice. We request that only primary caregivers bring children in for well checkups. Bloom Pediatrics requires that all our patients are immunized according to the current vaccine schedule recommended by the American Academy of Pediatrics.

Initials*
Missed Appointments

Cancellations are required 24 hours prior to any well visit appointment and two hours prior to any sick visit 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. Multiple missed appointments, per family, within a twelve-month period may result in dismissal from the practice.
Initials*
Late Arrivals

Appointment arrivals 10 minutes or later than the scheduled appointment time may result in the need to reschedule the appointment.
Initials*
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.
Initials*
Form Requests

A payment of $20 will be required prior to completing certain forms. You will be notified if the fee applies prior to completing the request. Examples: Family Medical Leave Act, leave of absence, camp forms, allergy/asthma action plan, specialty school forms, etc...
Initials*
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.
Initials*
Divorce

In the case of divorce or separation, the parent authorizing treatment for the child/children, i.e., the parent or HIPAA authorized adult present for the appointment will be the person responsible for the subsequent charges. Should the divorce decree designate a particular parent as payor for all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the responsible party and not the responsibility of Bloom Pediatrics.
Initials*
Respect

Treat Bloom Pediatric team members with respect and refrain from physical and verbal language or behavior that is offensive, abusive, or intimidating.
Initials*
Family Dismissal

Bloom Pediatrics reserves the right to terminate the patient/practice relationship at any time due to violation of the practice policies.
Initials*

Disability Champions / MVP - 2025
Bloom Pediatrics has been certified as a Most Valuable Provider (MVP). MVP’s offer vaccination and physician office experiences that are accessible and welcoming to all people across Michigan, including people with disabilities. We have worked with The Autism Alliance of Michigan, Disability Rights Michigan, and the Michigan Developmental Disabilities Institute to achieve this certification.
Does your child(ren) need special accommodations or identify as having a disability?*
Childs Name

First & Last NameDate of Birth
Childs Name

First & Last NameDate of Birth
Childs Name

First & Last NameDate of Birth

Credit Card on File Policy - 2025
Bloom Pediatrics requires that a valid Credit Card be kept on file (debit card not recommended). This policy applies to each child within a family.

The policy is designed to:

•       Help avoid all billing related fees

•       Streamline the billing process and eliminate the expenses related to handling overdue accounts

•       Focus our time and energy on your children and their medical care

The card information is stored electronically in an encrypted form and cannot be viewed by our team.

How the policy works:

1. At the time of your registration or check-in, you will be asked for your credit card information to be electronically stored in encrypted form on our computer. Only the last four digits are visible to our staff.

2. We will bill your insurance carrier as a courtesy for all charges related to the visit.

3. After receiving an EOB from your insurance company, a statement will be generated to the address on file for your records/review. After this statement has been generated, a separate letter will then be sent notifying you of the amount we intend to charge to your credit card on file. The credit card on file will be processed 14 days after the date on this letter, should the balance remain unpaid.

4. Coordination of benefits are the responsibility of the insurance holder. The credit card on file will be charged if the coordination of benefits is not completed and the account becomes past due.

5. If we attempt to use your card and it is declined or has expired, we will send you a new statement with a note attached asking for current credit card information.

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. If you feel we have charged your card in error, contact our office ASAP. If a mistake has been made, we will reverse the charges.

My signature below certifies that I have read and consent to the Credit Card on File policy. I agree to provide my credit card information to Bloom Pediatrics for the sole purpose of payment for my child(ren)s medical care. I have the right to cancel this process and use another form of payment.

Until further notice, I authorize Bloom Pediatrics to charge the patient-responsible balances on my account.
Signature

Clear

Financial Policy - 2025
Thank you for choosing Bloom Pediatrics as your child’s health care provider. The following is a copy of our financial policy. Patient care is not permitted without the written consent of receipt and acknowledgement of the understanding of this policy. This policy applies to each child within a family.
Payments

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.
Initials*
Self Pay

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.
Initials*
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.
Initials*
Outstanding Balances

If you have a personal balance on your account, a monthly statement will be sent. Unless authorized in writing, payment is due upon receipt of statement. The credit card on file will be processed 14 days after the date on this letter, should the balance remain unpaid. We make every effort to help you understand your balance once it has been processed by insurance. Balances unpaid after 60 days may result in an appointment being canceled or prevent new appointments from being scheduled.
Initials*
Payment Plans

Bloom Pediatrics understands that full payment may not be possible in certain circumstances. As a courtesy, Bloom Pediatrics may offer the assigned account holder a payment plan. Payment plans are approved on a case-by-case basis and may be discussed with our management team. Patients with a payment plan must be in full compliance with all conditions of the agreement at time of visit. Failure to make scheduled payments on the payment plan, or not paying off a balance in full, may result in your account being turned over to a collection agency and your family being dismissed from the practice.
Initials*
Collection Accounts

If your account is submitted to a collection agency, all associated fees are the responsibility of the assigned account holder, including a collection fee equal to 50% of the collection balance. The assigned account holder will receive written notification by way of a dismissal letter and given 30 calendar days to find a new health care provider. If your account is sent to collections and then paid in full, the assigned account holder may request the practice reinstate the account. If the practice permits reinstatement, there is a $25 reinstatement fee to be charged to the account holder. The fee must be paid prior to scheduling any future appointments.
Initials*
Returned Check Fee

A $30 fee will be charged for any checks returned for insufficient funds.
Initials*
Insurance:

We accept most insurances including most Medicaid plans. Please call the office to confirm acceptance of your coverage.

A scanned copy of the assigned account holder’s current insurance card and driver’s license is required to be kept on file. Please present newly issued insurance cards upon check-in at the next scheduled visit.

If you have an HMO insurance plan, please assign one of the physicians in our practice as your child’s primary care physician (PCP) prior to your visit. If we cannot confirm that one of our providers is listed as your child’s PCP, we will ask that the appointment be rescheduled.
Initials*
Change of Insurance/Change of 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.
Initials*
Billing Inquiries

Questions about a bill should be directed to our billing department at 1-866-371-6118.
Initials*
Review and consent of this policy is required prior to services rendered.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
My Kids' Chart Patient Portal
Patient Portal Access

Access to records is available for all children under 18 years of age. When a patient turns 18 years old in the State of Michigan, by law, their record automatically becomes private. They may grant permission to a parent or guardian to access their chart by signing an additional release form.

Please list the name and email of the parent/guardian that would like access to the patient portal.
Parent/Guardian Name*

First NameLast Name
Email Address*
example@example.com
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Notice of Privacy Practices
Bloom Pediatrics providers and staff are governed by and comply with the federal Health Insurance Portability and Accountability Act (HIPAA). We are required to 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 at the time. A copy of our current HIPAA statement is available upon request.

Patients age 18 and older are required to sign a waiver authorizing parental access to their account. Parents of patients over the age of 18 will not be permitted to access any medical or billing information without written consent of patient.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Please sign the “Acknowledgement” below to acknowledge that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.
Acknowledgement

I have read the above HIPAA Privacy Policies. As indicated above, I know my rights as a parent or as a patient over the age of 18, and also know and agree to the policies and procedures set in place by Bloom Pediatrics.
Parent/Guardian or Patient 18 and Older Name*

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date

Authorization for Other Caregivers
I want to authorize additional caregivers to give consent to treatment for the patient(s).*

YesNo
Authorization for Caregivers Other Than Parent or Guardian

The people listed below are designated as our agent to give consent (verbal or written) to surgical or medical treatment by any licensed physician or provider at Bloom Pediatrics for my minor child, and to receive relevant protected health information. Such consent may include but is not limited to, administration of necessary anesthetics, medical treatment, test, X-ray examinations, transfusions, injections, immunizations or drugs and the performing of whatever procedures may be deemed necessary or advisable.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide the authority to consent thereto as our said agent and the above-named child’s attending physician, in the exercise of their best judgement, may deem advisable. This authorization shall remain effective unless revoked in writing by the undersigned.
Caregiver 1 Name*

First NameLast Name
Relationship to Patient*
Caregiver 2 Name

First NameLast Name
Relationship to Patient
Caregiver 3 Name

First NameLast Name
Relationship to Patient
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Family Registration

Instructions

Patients

Release of Medical Records

Physican Releasing Records

Releasing Records To

Authorization

Insurance

Primary Insurance

Secondary Insurance

Medicaid

Insurance Authorization and Assignment (Please Read and Sign)

Family Demographics

Family Medical History

Policies and Procedures

Consent to Examine and Treat a Minor

Patient Privacy

Well Visits and Vaccines

Missed Appointments

Late Arrivals

Records Requests

Form Requests

Referrals

Divorce

Respect

Family Dismissal

Disability Champions / MVP - 2025

Credit Card on File Policy - 2025

Financial Policy - 2025

Payments

Self Pay

Missed Co-Pays

Outstanding Balances

Payment Plans

Returned Check Fee

Insurance:

Change of Insurance/Change of Account Information

Billing Inquiries

My Kids' Chart Patient Portal

Patient Portal Access

Notice of Privacy Practices

Acknowledgement

Authorization for Other Caregivers

Authorization for Caregivers Other Than Parent or Guardian