Bloom Healthcare Referral - CO Form
10900 W 44 th Street, Suite 200
Wheat Ridge, CO 80033
Phone (303) 993-1330 • Fax (303) 957-5757
PLEASE KEEP FOR YOUR RECORDS
Our Goal To provide the highest quality medical care to our homebound population
What we provide? We offer a wide variety of services to our patients including primary care, episodic care, wound consultations, palliative care, hospice evaluations, competency evaluations, fall assessments, and home safety evaluations.
Where do we go? We serve our patients in their private homes, assisted living centers, senior apartments, and independent living centers in the Denver metro area as well as Fort Collins.
Insurance Accepted We accept most insurance plans with the exception of Kaiser. Please note that it is the responsibility of the patient/power of attorney to ensure that the patient's insurance will cover services provided by Bloom Healthcare. In the event that insurance does not cover our services, any balance owed will be the responsibility of the patient.
Hours of Operation Our standard hours of operation are 8:00 a.m. to 5:00 p.m. Monday through Friday. Most patient visits will take place within these hours.
Preparing for Your Visit Be advised that due to the nature of mobile medicine, we are unable to provide exact appointment times. Please be prepared for your visit by wearing loose fitting comfortable clothing. Additionally, be sure to have your medications and medication list ready for review along with pertinent medical records. This will help ensure we provide you the best medical care. If a family member wishes to be present please contact our office to make arrangements. If you have trouble getting to and from the door for the visit please consider having a family or friend present or using a door side lockbox.
During Your Visit The initial visit is comprehensive and includes all past and current medical conditions, patient specific goals, and ordering of appropriate treatments. Typical initial visit length is over one hour. Follow up intervals and visits vary according to medical need. Assisted living patients must be seen at least four times a year due to state regulations.
After Your Visit Our office processes the orders for home health agencies, hospice, durable medical equipment, oxygen and pharmacy, simplifying your medical care. We also assign an approximate follow up date at the end of your visit. Our office will call you or your contact person to arrange the details. If you should have a change in condition or question about your care, please call our office.
Emergencies In a life threatening emergency please call 911 or go to the nearest emergency room. If an urgent medical problem arises during a time when the office is closed, simply call the office at (303) 993-1330 and you will have access to the on-call provider.
LOCAL PHARMACY: At least 7 days prior to needing your medication please have your pharmacy eprescribe our office and request a refill.
MAIL ORDER PHARMACY: Please have your pharmacy request refills from our office by eprescribe. We do NOT initiate fax prescriptions to mail order pharmacies.
NARCOTICS: Schedule II prescriptions cannot be called or faxed to pharmacies. If you require schedule II medications it is your responsibility to call our office at least 14 days prior to the end of your prescription, this will ensure ongoing coverage.
Medication Storage Your medications bottles and medication list should be stored in a box, a shoe box works well. If needed, pills can then be distributed into daily pill minders. This box of medication should be available at the time of a visit. Always store your medications safely and out of reach of children.
Letters and Forms Unless done as part of a provider visit there is a $40 charge for letters and forms that need to be completed and signed by our office. Examples include VA benefit forms, long-term disability forms, letters of competency, guardianship and conservator letters and jury letters. Please allow 7 days for completion.
Contacting Us Our office number is (303) 993-1330; our FAX is (303) 957-5757. For urgent medical needs please call our main number. Call coverage is provided 24 hours a day though visits typically take place only during office hours. In an emergency call 911.
Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Any remaining balance or denied service will be billed to the patient. Any changes to your insurance coverage must be reported in writing to our office. Failure to do so may result your financial responsibility.
Chronic Care Coordination services (CCM) Bloom Healthcare provides chronic care management services (CCM) for our patients. CCM involves a combination of face-to-face and non-face-to-face services to ensure that each patient’s healthcare needs are met. The non-face-to-face component of CCM involves the creation of a patient-centered plan of care, medication monitoring, management of care transitions, electronic care coordination and exchange of health information with other health care providers as necessary, while providing you or your caregiver 24/7 access to your care team. Bloom Healthcare will bill my insurance for this service, and patients are responsible for any copayment or deductible. Any patient can revoke permission to bill CCM at any time by notifying Bloom Healthcare in writing.
Medical Records Should the need arise your medical records can be faxed directly to any other medical provider free of charge. Should you also need a hard copy of your records there will be a minimum charge of $35. A release of information request may need to be completed prior to transfer of records.
Missed Appointments A missed appointment fee of $75 will be charged to anyone not calling to cancel their appointment at least 24 hours in advance.
Hospitals While we do not round at hospitals, we work closely with hospitalists serving these facilities. We provide ongoing communication between these providers and our office to ensure coordination of care. This allows our patients to choose any hospital they wish.
Testing in the Home We can arrange a variety of home testing including blood draws, x-ray, ultrasound, echocardiogram, circulation testing, and pulmonary function testing. Depending on the test and insurance there may be a fee that is not covered by insurance.
Home Health We work with most agencies ensuring ongoing communication and care of the medically complex home bound patients. Home health services available include physical therapy, occupational therapy, skilled nursing, speech therapy, home health aide, and homemaker services. Insurance limitations apply.
Hospice Due to the nature of our practice some of our patients choose hospice when appropriate. We continue to work closely with the hospice team and coordinate care as the patient's attending.
Denver is fortunate to have a good selection of excellent hospice providers. Please contact our office for further details.
Social Security #:
City, State, Zip:
How did you hear about Bloom Healthcare?
If patient is a new move in, please include move in date:
Medicare ID #:
Primary Policy #:
Secondary Policy #:
Support at Home
City, State, Zip:
Relationship to Patient:
POA (power of attorney): YesNo
Relationship to Patient:
POA (power of attorney): YesNo
My signature and date below authorizes/acknowledges each of the following:
SIGN, DATE AND RETURN THIS PAGE IMMEDIATELY! In order for us to bill Medicare and/or other insurance for your medical supplies and/or medications, this page must be completed, signed, dated and returned immediately.
Relationship to patient:
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Document Name: Bloom Healthcare Referral - CO Form
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