Forms

You are expected to complete the Patient Registration Form.  All other forms need to be completed only if they apply to your child’s need.

• Form (PDF) — Patient Registration Form

• Other Forms (PDF)

  • School Physical Form

  • Sports Physical Form

  • Refusal to Consent to Vaccination Form

  • ADD – ADHD Questionnaire TEACHER

  • ADD – ADHD Questionnaire PARENT

• State of Michigan Healthcare Forms

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Insurance

• Aetna

  • Aexcel Plus PPO

  • Aexcel PPO

  • Aexcel PPO (Aetna HealthFund)

  • Open Choice PPO

• American Republic Insurance Company

  • First Health

  • PHCS PPO

• Anthem Blue Cross

  • Blue Cross PPO (Prudent Buyer)

  • Lumenos Plans (PPO)

  • PPO Share

  • Premier Plus PPO

• Anthem Blue Cross Blue Shield

  • Blue Access Choice (PPO) (Missouri)

  • Blue Access Network (Indiana)

  • Blue Access PPO

  • Blue Cross PPO (Prudent Buyer)

  • Health Choice (Health Choice PPO)

  • National PPO (BlueCard PPO)

  • PPO (Colorado)

  • PPO (Connecticut)

  • PPO (Nevada)

  • PPO/EPO

  • Preferred Blue

  • Preferred Blue for PPO (New Hampshire)

  • Premier (Connecticut)

• Arkansas Blue Cross Blue Shield

  • Arkansas FirstSource PPO

  • Blue Select (PPP)

  • Blue Solution PPO

  • BlueCare PPO

  • Comprehensive Blue PPO

  • HSA Blue PPO

  • True Blue PPO

• Assurant Health

  • Assurant Health Access

  • Cigna PPO

• Blue Cross Blue Shield

  • BlueCard PPO

  • BlueCard PPO Basic

• Blue Cross Blue Shield of Alabama

  • Blue Advantage (PPO)

  • Preferred Provider Organization (PPO)

• Blue Cross Blue Shield of Arizona

  • Acclaim PPO/EPO

  • Alliance PPO/EPO

  • Indemnity

  • PPO/EPO Statewide

  • Secure HMO Network

• Blue Cross Blue Shield of Florida (Florida Blue)

  • BlueOptions

• Blue Cross Blue Shield of Georgia

  • Anthem Medicare Preferred PPO

  • Blue Choice PPO

  • Blue Choice PPO, PPO, EPO

  • BlueChoice Preferred Provider Organization (PPO)

• Blue Cross Blue Shield of Illinois

  • BasicBlue PPO

  • Blue Choice PPO

  • Blue Choice Preferred Bronze PPO

  • Blue Choice Preferred Gold PPO

  • Blue Choice Preferred Security PPO

  • Blue Choice Preferred Silver PPO

  • Blue PPO Bronze

  • Blue PPO Gold

  • Blue PPO Silver

  • Participating Provider Organization [PPO]

  • TraditionalBlue PPO

• Blue Cross Blue Shield of Kansas

  • AffordaBlue

  • BasicBlue

  • Blue & U Classic (Copay)

  • Blue & U First

  • Blue Choice

  • Traditional

• Blue Cross Blue Shield of Kansas City

  • BlueAccess

  • BlueCard Traditional

  • Preferred-Care Blue

• Blue Cross Blue Shield of Louisiana

  • Blue Cross and Blue Shield of Louisiana Multi-State Plan

  • BlueMAX

  • BlueSaver

• Blue Cross Blue Shield of Massachusetts

  • Advantage Blue

  • Blue Care Elect (PPO/EPO)

  • Blue Precision/PPO Blue Options v.4

  • PPO Network with Hospital Choice Cost Sharing feature

  • Preferred Blue PPO

  • Preferred Blue PPO Options v.4

• Blue Cross Blue Shield of Michigan

  • Community Blue/Blue Preferred Plus PPO

  • Michigan Conference of Teamsters Welfare Fund (MCTWF) PPO

  • MIChild

  • MPSERS

  • PPO Plans – Group Enrollees

  • Traditional – Group Enrollees

• Blue Cross Blue Shield of Minnesota

  • Allina Health Network (Blue Plus)

  • Blue Access Choice

• Blue Cross Blue Shield of Mississippi

  • Network Blue

• Blue Cross Blue Shield of Montana

  • Blue Preferred Bronze PPO

  • Blue Preferred Bronze/Silver/Gold/Platinum PPO

  • Blue Preferred Gold PPO

  • Blue Preferred PPO (PPO)

  • Blue Preferred Security PPO

  • Blue Preferred Security PPO

  • Blue Preferred Silver PPO

• Blue Cross Blue Shield of Nebraska

  • Beatrice BlueChoice

  • Boone County BlueChoice

  • Methodist BlueChoice

• Blue Cross Blue Shield of New Mexico

  • Blue PPO Bronze/Silver/Gold

  • Blue PPO Evolution

  • Blue PPO Options

  • Blue PPO Platinum

  • Blue Security PPO

  • Blue Transitions (EPO)

  • BlueDirect (PPO)

  • BlueNet EPO

  • Preferred Provider Organization (PPO)

• Blue Cross Blue Shield of North Carolina

  • Blue Care

  • Blue Options

• Blue Cross Blue Shield of North Dakota

  • Preferred Blue PPO

• Blue Cross Blue Shield of Oklahoma

  • Blue Advantage Bronze PPO

  • Blue Advantage Gold PPO

  • Blue Advantage PPO

  • Blue Advantage Silver PPO

  • Blue Choice Bronze PPO

  • Blue Choice Gold PPO

  • Blue Choice Silver PPO

  • Blue Preferred Bronze PPO

  • Blue Preferred Gold PPO

  • Blue Preferred Security PPO

  • Blue Preferred Silver PPO

  • BlueChoice (PPO)

  • BlueOptions PPO

  • BluePreferredBluePreferred PPO

• Blue Cross Blue Shield of Rhode Island

  • BlueSolutions

  • Bryant University Healthplan

  • HealthMate Coast-to-Coast

  • VantageBlue

• Blue Cross Blue Shield of South Carolina

  • BlueCard PPO Basic

  • Preferred Blue – PPO

• Blue Cross Blue Shield of Tennessee

  • Blue Advantage PPO

• Blue Cross Blue Shield of Texas

  • Blue Choice Platinum PPO

  • Blue Choice Silver PPO

  • BlueChoice PPO Plan

  • BlueOptions

  • EPO

  • UT Select PPO

• Blue Cross Blue Shield of Vermont

  • BCBSVT Network Providers

  • New England Health Plan

• Blue Cross Blue Shield of Wyoming

  • Participating Provider (PPO)

• Blue Cross of Idaho

  • Connected Care (East)

  • PPO

• Blue Cross of Northeastern Pennsylvania

  • AffordaBlue

  • BlueCare Custom PPO

  • BlueCare EPO

  • BlueCare PPO

  • BlueCare QHD EPO

  • BlueCare QHD PPO

• Blue Shield of California

  • Active Choice Plans

  • Base PPO 30

  • Blue Shield of California PPO Network

  • Point of Service (POS)

  • Premier PPO 15

  • Shield Spectrum PPO 750 – 80/60

  • Trio ACO HMO

• Blue Shield of Northeastern New York

  • EPO

  • PPO

• Capital Blue Cross

  • PPO

  • PPO Choice 1

  • PPO Choice 2

• CareFirst Blue Cross Blue Shield

  • BlueChoice Advantage

  • BluePreferred

  • HealthyBlue Advantage

  • Preferred Provider Organization (PPO)

• Caterpillar

  • UHC PPO Network Plan

• CBA Blue

  • BlueCard PPO

• CHAMPVA

  • CHAMPVA

• Cigna

  • Choice Fund PPO

  • Cigna PPO

• Cofinity

  • PPO

• DMC Care

  • DMC Care

• Empire Blue Cross Blue Shield

  • Empire EPO Essential

  • Empire PPO

  • Empire Prism EPO

  • Empire Prism PPO

  • PPO

  • Value EPO

• First Health (Coventry Health Care)

  • First Health Network PPO

• Florida Blue: Blue Cross Blue Shield of Florida

  • BlueOptions

• GeoBlue

  • GeoBlue Expat

  • GeoBlue Traveler

• GWH-Cigna (formerly Great West Healthcare)

  • PPO

• HAP (Health Alliance Plan)

  • HAP Preferred

• Harbor Health Plan

  • Harbor Health Advantage

• Health Net

  • National PPO – First Health

• HealthPlus of Michigan

  • HealthPlus Options

  • HealthPlus Options PPO

  • HealthPlus PPO

• HighMark Blue Cross Blue Shield

  • BCBS PPO

  • PPOBlue

• Highmark Blue Cross Blue Shield of Delaware

  • BCBS EPO

  • BCBS PPO

  • PPO

  • PPO Blue Total Health

• HighMark Blue Shield

  • PPOBlue

• Horizon Blue Cross Blue Shield of New Jersey

  • Horizon Advantage EPO (with BlueCard PPO)

  • Horizon PPO

• Humana

  • Humana Preferred PPO

  • Humana Select Network PPO

  • Humana/ChoiceCare Network PPO

  • HumanaChoice (PPO)

  • HumanaPPO

• Independence Blue Cross

  • National BlueCard PPO

  • Personal Choice PPO

• Magellan Health

  • Behavioral Health Program

• McLaren Health Plan

  • McLaren Health Advantage

• Medicaid

  • Fee For Service (FFS)

  • Medicaid

• Medical Mutual

  • SuperMed Plus (PPO)

• Memorial Hermann

  • MultiPlan

  • PHCS

• Moda Health

  • PHCS

• Molina Healthcare

  • MI: Molina Healthcare of Michigan MIChild Health Plan

  • Molina Silver 87 HMO

  • Molina Silver 94 HMO

• Multiplan PHCS

  • Multiplan

  • PHCS

• Paramount Healthcare

  • Advantage

  • CDHP

  • Elite – Michigan Residents

  • Elite – Ohio Residents

  • Employer Select

  • Flex / Flex Plus (PHC)

  • Flex / Flex Plus (PICO)

  • Individual Marketplace

  • MAP

  • Medigap

  • Michigan HMO

  • Ohio HMO (PHC)

  • Ohio HMO (PICO)

  • PPO

  • Prestige – Michigan Groups

  • Prestige – Ohio Groups (PHC)

  • Prestige – Ohio Groups (PICO)

  • Steps2Health / Medical Home (PHC)

  • Steps2Health / Medical Home (PICO)

  • Traditional Plan

• POMCO

  • POMCO-PHCS/Multiplan

• Premera Blue Cross

  • AK Global with BlueCard PPO/Traditional

  • AK HeritagePlus with BlueCard PPO/Traditional

  • AK HeritageSelect with BlueCard PPO/Traditional

  • Foundation & Foundation Plus 1 with BlueCard PPO/Traditional

  • Global with BlueCard PPO/Traditional

  • Heritage & Heritage Plus 1 with BlueCard PPO/Traditional

  • Heritage Prime with BlueCard PPO/Traditional

  • Heritage Signature with BlueCard PPO/Traditional

  • Premera BlueCard PPO/Traditional Network

• Priority Health

  • PriorityPPO

• Regence Blue Cross Blue Shield

  • Oregon Select OHSU

  • Preferred (PPO)

  • RealValue

• Total Health Care

  • Employer Sponsored HMO

  • Employer Sponsored HMO PPN

  • Employer Sponsored POS

  • Employer Sponsored POS PPN

  • Individuals & Families HMO

  • Medicaid and Healthy Michigan Plan HMO

  • MIChild HMO

  • SHOP HMO

  • Total Gold Complete

  • Total Gold Premier

  • Total Gold Signature

  • Total HMO Standard

  • Total Platinum Complete

  • Total Platinum Premier

  • Total Platinum Signature

  • Total Platinum Ultimate

  • Total Value Complete

  • Total Value Plus

  • Total Value Signature

  • Totally You

• Triple-S Salud: Blue Cross Blue Shield of Puerto Rico

  • Commercial (PPO)

  • Federal

  • Federal BCBS

• UnitedHealthcare

  • UnitedHealthcare Options Non-Differential PPO

  • UnitedHealthcare Options PPO

  • UnitedHealthcare Options PPO with Harvard Pilgrim

• UnitedHealthOne

  • UnitedHealth Allies

  • UnitedHealthcare Navigate

  • UnitedHealthcare Navigate Plus

• US Health Group

  • Private Healthcare Systems (PHCS) (PPO)

• Wellmark Blue Cross Blue Shield

  • Alliance Select (Iowa)

  • Blue Choice (Iowa and Bordering Counties)

  • Blue Rewards POS

  • Blue Select (South Dakota)

• Workers’ Compensation

  • Farmers Insurance

  • Liberty Mutual