Bloom Healthcare Referral - CO Form


Bloom Health Care

 

10900 W 44 th Street, Suite 200
Wheat Ridge, CO 80033
Phone (303) 993-1330 • Fax (303) 957-5757

 

 

New Patient Resources

Practice Policies
Notice of Privacy Practices

 

PLEASE KEEP FOR YOUR RECORDS

 

Practice Policies

 

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.

 

Medication Refills

 

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.

 

 

 

 

Bloom Healthcare Referral

Please review, sign and return.

 

Name of Community: 

Patient Name:
Sex:


DOB: 
Social Security #:
Street Address:
APT/ROOM #:
City, State, Zip:
Phone:
Fax:
How did you hear about Bloom Healthcare?

 

If patient is a new move in, please include move in date:

Living Arrangement

 

 

Insurance

Medicare ID #:
Primary Insurance:
Primary Policy #:
Secondary Insurance:
Secondary Policy #:

 

 

 

 

Medication List (including allergies)

 

 

Pharmacy

Pharmacy Name:
Pharmacy Phone:
Pharmacy Address:

 

 

Social History (Please check all that apply)

Diet

Other:

Support at Home

Other:

Race (Optional)

 

 

Billable party (if other than patient)

Name:
Street Address:
City, State, Zip:
Phone:
Relationship to Patient:
POA (power of attorney):

 

 

Primary Contact (if different than patient)

Name:
Phone:
Relationship to Patient:
POA (power of attorney):

 

 

Authorization to Bill

Please review, sign and return.

 

My signature and date below authorizes/acknowledges each of the following:

  1. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s) on my behalf.
  2. Release of my medical information to my insurance providers and their agents.
  3. Bloom Healthcare and/or any of their corporate affiliates to obtain medical or other information necessary in order to process claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided.
  4. I acknowledge that I have received a copy of the Bloom Healthcare Notice of Privacy Practices.
  5. There are certain services 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. The following charges may apply:

    • Missed Visit Fee $75
    • Formal Letter Requests $40
    • Records (free to MD office) $35
    • Care Plan Oversight (other than Medicare) $40
    • Long Term Care Form $40

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:

Leave this empty:

Bloom Healthcare https://bloomhealthcare.com
Signature Certificate
Document name: Bloom Healthcare Referral - CO Form
Unique Document ID: 26599483cc5ee095d14a8f04ac827f5472e70670
Timestamp Audit
December 20, 2018 9:59 pm MDTBloom Healthcare Referral - CO Form Uploaded by Consent Team - consents@bloomhealthcare.com IP 98.245.131.4
January 2, 2019 12:49 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - consents@bloomhealthcare.com as a CC'd Recipient Ip: 127.0.0.1
January 2, 2019 12:50 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - consents@bloomhealthcare.com as a CC'd Recipient Ip: 127.0.0.1
January 4, 2019 5:29 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - noreply@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:31 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - noreply@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:50 pm MDT Document owner noreply@bloomhealthcare.com has handed over this document to consents@bloomhealthcare.com 2019-01-04 18:50:19 - 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:50 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:53 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 6, 2019 5:39 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 6, 2019 5:41 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 7, 2019 10:46 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 7, 2019 10:50 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:39 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:48 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:50 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:52 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:53 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:56 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
January 17, 2019 9:57 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
February 4, 2019 5:19 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
February 4, 2019 5:27 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
February 4, 2019 9:19 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4