Insurance

  • Insurance

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

  • Patients

    List the name and date of birth for each child in your family who is a patient.

  • Patient 1 Date of Birth*
     - -
  • Patient 2 Date of Birth
     - -
  • Patient 3 Date of Birth
     - -
  • Patient 4 Date of Birth
     - -
  • Patient 5 Date of Birth
     - -
  • Patient 6 Date of Birth
     - -

  • Primary Insurance

  • Do you have primary insurance?*
  • Subscriber's Date of Birth*
     - -

  • 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.

  • Browse Files
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    Choose a file
    Cancelof
  • Browse Files
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  • Browse Files
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  • Secondary Insurance

  • Do you have secondary insurance?*
  • Subscriber's Date of Birth*
     - -
  • Start 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.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Medicaid

  • 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.

  • Date*
     - -
  • Should be Empty: