Annual Fee for Non-Covered Services


Enter the number of patients you will be paying for below. Additionally, please enter each patient’s full name and date of birth.

*Required Fields


Patient Information 1

Full Name
Please enter the patient's first name
Please enter the patient's last name
Date of Birth
Please enter a valid month.
Please enter a valid day.
Please enter a valid year.


Non-Covered Services are those services that Bloom OB/GYN performs that are not reimbursed by insurance companies. Typically, these services require considerable time in addition to your routine office visit. For example:

  • Access to on-site blood draws and ultrasound (may be excluded for certain HMO plans)
  • Calls to insurance companies and HR departments regarding insurance eligibility and billing questions
  • Coordination of care with specialists/ER doctors, pharmacies, laboratories or radiology departments
  • Letters to referring providers and for patients
  • Completing forms for work: disability, immunizations, etc.
  • FMLA forms
  • Prior authorization for laboratory tests or medications