REFERRAL FORM

How do I begin the process to obtain ABA services with Bloom Behavioral Health?

  • First step is to contact us (714) 203-6595
  • Download the insurance intake form and email at bloomadmin@bloombh.com, fax (714) 716-4433 or upload the document below along with a copy of your insurance card.
  • We will set up a free in-home consultation to get to know you and further understand your needs.
  • You will need the following documents in order to proceed.
    • REQUIRED: Comprehensive Diagnostic Evaluation (CDE) from a neurologist, licensed psychologist, or developmental pediatrician who diagnosed and prescribed ABA services.
    • If you do not have the diagnostic information, please complete the Authorization to Release Information Form and we will contact your physician to obtain the diagnostic information.
    • Supplemental documents such as Individualized Education Plan (IEP), speech/OT/PT evaluation, regional center documents, and a list of medications are recommended.

CALL US TODAY TO GET STARTED WITH ABA SERVICES

Our insurance representatives will assist you with eligibility, coverage, and copayments. You do not have to deal with the insurance plans, let us do the work for you.

Bloom Behavioral Health is an in-network provider with most insurance plans and medi-cal.

Our caring and compassionate insurance representatives will assist you with eligibility, coverage, and copayments.

KNOW YOUR RIGHTS

REQUIRED FORMS

CALL US TODAY (714) 203-6595

GET STARTED TODAY

Contact us and our insurance department will send you the initial insurance intake paperwork. You can also enter and upload your confidential information below and our insurance representative will contact you within 24 hours.

  • BLOOM BEHAVIORAL HEALTH REFERRAL FORM


We are an in-network provider for the following insurance plans and continue to contract with more. Please call us to see if we are contracted with your health plan. We are currently an in-network provider with following health plans:

  • Aetna
  • Cigna
  • MultiPlan
  • Value Options
  • Humana/Lifesynch
  • Blue Shield/Magellan
  • Beacon Health Options
  • CalOptima
  • Health Net
  • MHN
  • We are a Medi-Cal provider