Note: Bloom Health Network LLC and Physician Housecalls LLC are both affiliates of Bloom Healthcare Inc.

Selecting Bloom Healthcare or any other doctor or other health care professional by completing this form is your choice AND you can change your mind later. If you complete this form and select Bloom Healthcare (or any other doctor) as your main doctor or health care professional, you should do so yourself. No one else, other than a Power of Attorney or Legal Guardian, should complete this form for you.

No one is allowed to attempt to influence your choice to complete this form or select a doctor or other health care professional through Medicare.gov by offering or withholding anything in exchange for you to complete or not complete the form or to make a selection online. If you feel pressured to sign or not sign this form or to make a selection online, please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have questions, feel free to call Bloom Healthcare at 720-923-1302. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about “ACOs”. TTY users should call 1-877-486-2048.

If you change your mind later about whether you consider Bloom Healthcare to be the main doctor or other health care professional you see for routine care, you can call (303) 993-1330 or update your selection online, at anytime.

Importante: esta informacion esta disponibles en espanol, solicitalo llamando al (720) 923-1302.

You can also get more information about ACOs at the CMS Website