Bloom Healthcare Lab ABN Lab ABN Form First Name(Required) Last Name(Required) Email Address(Required) Identification Number(Required)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 Card Type (Visa, Discover, AMEX, etc.)(Required) Cardholder Name (as shown on card)(Required) Credit Card Number(Required)Expiration Date(Required) MM slash DD slash YYYY Cardholder Zip code(Required) Authorize Credit Card I have reviewed and authorize Bloom Healthcare to charge my credit card.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.(Alternative) Request to Pay By Check 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.NameThis field is for validation purposes and should be left unchanged.
