bloom healthcare

Lab ABN

Patient First Name

Email Address

Patient Last Name

Identification Number

Authorization to Bill
Please Sign & Return

There are certain services that Bloom Healthcare provides which are not covered by Medicare and most other insurances. These charges must be paid by the patient or their representative at the time of service.

Non-covered services include:
Home lab draw: $40 per trip

Please sign, date, complete the credit card authorization below, and return this page immediately in order to receive this non-covered service.

Credit Card Authorization

Please complete all fields. You may cancel this authorization at any time by contacting our office at 303.993.1330. This authorization will remain in effect until cancelled.

Credit Card Information

Cardholder Name (as shown on card)

Card Type (Visa, Discover, AMEX, etc.)

Credit Card Number

Expiration Date

Cardholder Zip code

By checking this box, I am electing to pay for the lab draw via check at the time of the visit rather than by credit card. Bloom is not able to accept cash and will not accept payment at a later date.

I authorize Bloom Healthcare to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transaction on my account.

Signing below means that you have received and understand this notice. You may also receive a copy.

“ Michelle Jenkins has been my mother’s primary care provider for the past 3+ years. Her attention to detail, the communication and follow up she provides and her thorough understanding of my mother’s needs is remarkable. She clearly cares about Mom and it shows! ”

~ Chuck F.

“ We couldn’t be better taken care of than we are at Bloom! We are so grateful and thankful to be under their care. Our provider is the best! ”

~ Mr. & Mrs. F.

My aging mother was falling through the cracks, in and out of assisted livings, rehabs after falls etc. I found Bloom and they came in and stabilized all! John and Angela as PA's were so caring and thorough. The staff at Bloom was so responsive, answering all questions promptly, and explaining things well to my mom. We were able to keep my mom home for awhile, but as she aged Bloom followed her to assisted living and beyond with an amazing continuum of care. I highly recommend Bloom, they are a great teammate in caring for our seniors, and a great resource especially during days of Covid!!

~ Susan G

Bloom is an incredible organization. They provide high quality care to patients and particularly serve those patients living alone at home or those living in a senior living community. The Bloom Team is empathetic and compassionate and always work towards treating the whole patient and takes into consideration the patient’s living environment and social dynamics. The Team also works diligently to collaborate with other providers and services involved in the care of those patients. The patient is always their priority. Thank you for all you do Bloom!

~ Jim M.

Since moving my mother to assisted living we have been using Bloom Healthcare to manage her care. She can still go see specialists as needed but Bloom has been wonderful to work with. I can always call for a concern and they follow through doing blood work or x-rays in her room then calling in needed prescriptions. They manage her med refills, and oversee her care at a level that brings me much peace. They are good at keeping me informed of what is needed and happening for my mother. Thank you!!

~ Marjie C

Lab ABN

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