Registration for Lactation Mothers
When an email address is provided, you will be web enabled for our patient portal:
If Mother's insurance is the same as child's insurance on file, please list child's name and birthdate below:
By signing below, I authorize Bloomington Pediatrics, LTD to submit claims for services rendered to the insurance company/companies listed by me. I authorize the release of protected health information to said insurance companies for the processing of claims. I understand that I am responsible for payment of services rendered and agree to pay any fees for services not covered by insurance, including, but not limited to coinsurance and deductible amounts. I agree to pay at the time of service any co-payment required by my insurance. I also understand I will be held responsible for the payment of any collection fees should my account be sent into collection proceedings.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
By signing below, I consent to and authorize the physicians, nurses and other healthcare providers at Bloomington Pediatrics, LTD to perform appropriate healthcare examinations, treatment, diagnostic testing or medication administration as deemed medically necessary by their professional judgment. I know that there are some risks with all medical treatments and procedures and I understand that no one can guarantee how well treatments or procedures will work.
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