Practice Policies and Procedures - 2025

2055 E 14 Mile Road Birmingham, MI 48009 (248) 645-1740 Fax (248) 645-5304 bloompediatricsmi.com

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.

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.

Well Visits & 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 the the current vaccine schedule recommended by the American Academy of Pediatrics. Insurance companies may differ in how they define and cover preventative services. As a result, you may be responsible for out-of-pocket costs such as deductibles, coinsurance, copays, or charges for non-covered services. Please review your insurance plan carefully to understand which preventative services are covered and how often, before receiving care

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.

Late Arrivals: Appointment arrivals 10 minutes or later than the scheduled appointment time may result in the need to reschedule the appointment.

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.

Forms Request: 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

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 ofthe specialist with whom you have an upcoming appointment, and your referral will be completed within 5 business days.

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.

Respect: Treat Bloom Pediatric team members with respect and refrain from physical and verbal language or behavior that is offensive, abusive, or intimidating.

Family Dismissal: Bloom Pediatrics reserves the right to terminate the patient/practice relationship at any time due to violation of the practice policies.

  

Disability Champions / Most Valuable Provider

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.

 

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 is generated, a seperate letter will then be sent notifying you of the amount we intend to charge 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.

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.

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.

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.

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. 

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.

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.Ifyour account is sent to collection 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.

Returned Checks: A $30 fee will be charged for any checks returned for insufficient funds.

After Hours/Holiday Care: There is a $40 fee visits that occur after 5:00pm (EST) daily, on weekend days and federal holidays. If that fee is not covered by your insurance carrier, the assigned account holder is financially responsible for the charges. While often necessary, I acknowledge that urgent and emergent care at outside facilities results in higher co-pays and rising healthcare costs.

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.

Change of Insurance/Change of Account Information: Please notify the office as soon as possible of all account changes, including co-pay amounts, insurance updates, and change of mailing address. If the account holder does not notify the office of these changes, the assigned account holder becomes responsible for all charges.

Billing Inquiries: Questions about a bill should be directed to our billing department at 1-866-371-6118.

Review and consent of these policies is required prior to services rendered.

Please list all children that are patients at Bloom Pediatrics. This signed document will apply to all children listed below.

My signature below certifies that have read and consent to the Practice Policies and Procedures, Financial Policy, and Credit Card on File Policy.

If you have any questions regarding the conditions and terms outlined in this document, please call our office at 248- 645-1740 and request to speak with a manager.