​Blue Cross/Blue Shield of Michigan Extract Form

Provider Instructions:

Please provide a brief description of the service you are providing and why the service may reject and not be paid
ALLERGEN EXTRACT - PER BCBSM RULES - PATIENT RESPONSIBILITY IS DETERMINED BY THE PATIENT NOTIFYNG PROVIDER OR BY CANCELLING APPOINTMENTS THAT THEY ARE NOT FOLLOWING THROUGH WITH THE TREATMENT OR TREATMENT IS NEVER STARTED

Provider Name(s): Allergy Associates of Western Michigan
3185 Macatawa Dr SW Suite B
Grandville, Michigan 49418-1274

Erica Palmisano, MD
1629367081

Thomas P. Miller, MD
18471210895

Member/Patient Information

Provider Instructions: Please fill in the fields below and have the Blue Cross member/patient sign and date the "Member's acknowlegement and agreement to pay for services" section.

Patient Name:

Date of Birth:

Member Name:

ID/Contract #:

Group name and number (excludes Medicare primary, Medicare Advantage and MESSA group members)

Date of Service:

Procedure code(s):

Total dollar amount of member responsibility:

MEMBER'S acknowledgement and agreement to pay for services

My health care provider has notified me that the services listed above may not be payable by Blue Cross Blue Shield of Michigan in the event treatment is not continued or treatment is not started. I understand that payment for these services will be my responsibility. I agree to be responsible for payment

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Member/Patient signature:

Date:

Your information will be encrypted.

​Blue Cross/Blue Shield of Michigan Extract Form

Provider Instructions:

Member/Patient Information

MEMBER'S acknowledgement and agreement to pay for services

Blue Cross/Blue Shield of Michigan Extract Form