New Patient Registration


Page 1

Bloom Health Care

 

10900 W 44th Ave, Suite 200
Wheat Ridge, CO 80033
Phone (303) 993-1330 • Fax (303) 647-3647

 

 

Referral Information

Please review and submit.

 

 

Name Of Community:

Type:

Patient Name:

Patient Sex:

Patient Date of Birth:
Patient Social Security #:
Patient Address (Street/APT/Room #):
Patient City/State/Zipcode:
Patient Phone #:
Primary Contact (if not Patient):

Is the Primary Contact The POA?

Primary Contact Phone #:
POA (If Different):
POA Contact Info:

 

Insurance information

 

Medicare ID #:
Primary Insurance Name:
Primary Insurance ID #:
Secondary Insurance Name:
Secondary Insurance ID #:
Home Health Provider:
Hospice Provider:

Medications:

Please Check All that Apply:

 

Diet:

 

Other Comments:

 

 

Consent Agreement for Provision of Chronic Care Management

Please review, sign and submit.

 

 

By signing this Agreement, you consent to Bloom Healthcare (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below.

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services.

 

Provider’s Obligations When providing CCM Services, the Provider must:

  • Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions.
  • Provide to you written or electronic copy of your care plan upon request.
  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.

 

Beneficiary Acknowledgment and Authorization By signing this Agreement, you agree to the following:

  • You consent to the Provider providing CCM Services to you.
  • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
  • You acknowledge that only one practitioner can furnish CCM Services to you during a calendar month.
  • You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider.

 

Beneficiary Rights You have the following rights with respect to CCM Services:

  • The Provider will provide you with a written or electronic copy of your care plan.
  • You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally (by calling 303.993.1330) or in writing (to 10900 W 44 th Ave, Suite 200, Wheat Ridge, CO 80033). Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

 

 

Patient Name:
Patient Date of Birth:
If not signed by patient, list personal representative’s authority to act for the patient:

 

 

Leave this empty:

Bloom Healthcare https://bloomhealthcare.com
Signature Certificate
Document name: New Patient Registration
Unique Document ID: e02a302742f65a5d69009551def939afce052c2b
Timestamp Audit
August 30, 2019 10:27 am MSTNew Patient Registration Uploaded by Consent Team - consents@bloomhealthcare.com IP 76.25.252.106
September 4, 2019 8:25 pm MST Document owner noreply@bloomhealthcare.com has handed over this document to consents@bloomhealthcare.com 2019-09-04 20:25:06 - 98.245.131.4