Bloom Healthcare Confirmation of main doctor or other healthcare professional Confirmation of main doctor or other healthcare professional form DISCLAIMER Your benefits will NOT change, and you can visit any doctor, other health care professional, or hospital. Whether or not you complete this form or select a doctor or other health care professional through Medicare.gov, you remain eligible to receive the same Medicare benefits and you still have the right to use any doctor, other health care professional, or hospital that accepts Medicare, at any time. If you have questions, feel free to ask your doctor or other health care professional or Bloom Healthcare at 720-923-1302, or call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about DCEs. TTY users should call 1-877-486-2048. Completing the form below or selecting a doctor or other health care professional through Medicare.gov is your choice AND you can change your mind. If you choose to complete this form or select a doctor or other health care professional through Medicare.gov you should do so yourself. No one else should complete this 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. Importante: esta informacion esta disponibles en espanol, solicitalo llamando al (720) 923-1302. You can also get more information about DCEs at the CMS Website CONFIRM By signing this form, I am confirming that my main doctor or other healthcare professional I receive routine medical care from is Physician Housecalls d/b/a BLOOM HEALTHCARE Are you the patient?(Required) Yes No Are you the power of attorney or legal guardian?(Required) Yes No Email address(Required) First Name(Required) First Name Last Name(Required) Last Name POA/Legal Guardian First Name POA/Legal Guardian Last Name Note: If the names listed above and in the attached letter are incorrect do not sign this form. If you would like to receive a new form with a different doctor, other healthcare professional, or practice listed, please call Bloom Healthcare at (720) 923-1302 to request a new form. Completing and returning this form is voluntary. It won’t affect your Medicare benefits.PhoneThis field is for validation purposes and should be left unchanged.
