Patient Registration

Patient Info

Tell us about the patient whom you are submitting:

Where did you hear about us?*

Type of Residence*

Name of Community

If Patient is a new move in, please include move in date

Patient First name*

Patient Last Name*

Patient Date of Birth*

Patient Home Address **

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Phone Number*

Allergies

Pharmacy Name

Pharmacy Address

Pharmacy Phone Number

Gender Identity*

Are you Hispanic/Latin/a/o/x?*

Yes

No

Decline to Provide

Patient Language*

Race(s) check all that apply:*

Patient’s Email:

Patient Social Security Number

Is the Patient the Primary Contact*

No

Yes

Primary Contact's Full Name

Relationship to Patient

Primary Contact's Phone Number

Primary Contact's Address

Does the Patient Have a Power of Attorney*

Yes

No

POA’s Full Name

POA Contact Information:

Any Additional Contact Information:

Do you have Medicare?*

Yes

No

Do you have additional primary insurance other than Medicare (i.e. United, BCBS, Humana, etc

Yes

No

Do you have a secondary/supplemental insurance?

Yes

No

Hospice Provider:

If applicable

Home Health Provider:

If applicable

List all current medications including dosages and frequencies*

Please Check All that Apply

Diet

Regular

Diabetic

Low Salt

Other Comments:

Attach any relevant files here:

Max. file size: 64 MB.

Privacy Statement*

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your health information is personal, and we are committed to protecting it. We use and disclose health information about you for treatment, to obtain payment for treatment, for administrative purposes, to evaluate the quality of care that you receive, and for other purposes permitted by HIPAA. We are required by law to maintain the privacy of your health information, to provide you a notice of our legal duties and privacy practices, and to provide you with notice of a breach of your unsecured protected health information. We are required to abide by the terms of this Notice. We reserve the right to change our privacy practices, as reflected in this Notice, to revise this Notice, and to make the new provisions effective for all protected health information we maintain. Revised Notices will be available in our office, on our website, or upon your request. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. The terms “information” and “health information” in this notice include any information we have that reasonably can be used to identify you and that relates to your physical or mental health condition, the health care you receive, or the payment for such health care.

How Bloom Healthcare May Use or Disclose Your Health Information. We may use or disclose your health information, in certain situations, without your consent or authorization. Below we describe examples of how we may use or disclose your health information as permitted under or required by federal law, including instances where we will obtain your consent or authorization. Such uses or disclosures may be in oral, paper, or electronic format.

For Treatment. We may use and disclose your health information to provide you with medical treatment or services or to assist in the coordination, continuation, or management of your health care and any related services. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to treating physicians or others involved in your care.

For Payment. We may use and disclose your health information to others for purposes of obtaining payment for treatment and services that you receive. For example, a bill may be sent to you or to a third-party payer, such as an insurance company or health plan, for care, items or services provided to you.

For Health Care Operations. We may use and disclose health information about you for operational purposes. For example, your health information may be used by us or disclosed to others in order to: communicate with you about our clinical activities and services; assess the quality of care; or train our health care professionals.

Communications. We may use and disclose your information for appointment reminders, leave a message on your voicemail, or leave a message with an individual who answers the phone at your residence.

Required or Permitted by Law. We may use and disclose information about you as required or permitted by law, which may include: for judicial and administrative proceedings; to assist law enforcement; and in the instance of a breach involving your health information.

Public Health. Your health information may be used or disclosed for public health activities such as: assisting public health authorities to prevent or control disease; reporting child abuse or neglect; reporting information to the Food and Drug Administration related to safety or quality issues, or adverse events; or notifying a person who may be at risk of contracting or spreading a disease.

Individuals Involved in Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.

Clinical Trials and Other Research Activities. We may use and disclose your health information for research purposes without an authorization from you if the research study meets federal privacy law requirements.

Health and Safety. We may, consistent with applicable law and standards of ethical conduct, use or disclose health information about you if we believe that the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of a person or the public.

Notification and Disaster Relief. We may use or disclose your health information to notify or assist in notifying your family, a personal representative, or another person responsible for your care, of your location, condition, or death.

Decedents. Health information may be disclosed to funeral directors, medical examiners or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donation. Your health information may be used or disclosed for cadaveric organ, eye or tissue donation and transplantation purposes.

Government Functions. We may disclose your health information for specialized government functions, such as military and veterans’ activities, national security activities, and protection of public officials.

Workers’ Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to workers’ compensation.

Business Associates. We may contract with one or more third parties (our business associates) in the course of our business operations. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. Business associates are required, under contract and pursuant to federal law, to protect the privacy of your information and are not allowed to use or disclose any information other than as stated in our contract and permitted by law.

Authorizations for Other Uses and Disclosures. While we may use or disclose your health information without your written authorization as explained above, there are other instances where we will obtain your written authorization. This includes, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization. Also, the confidentiality of alcohol and drug abuse treatment records, HIV-related information, and mental health records maintained by us is specifically protected by state and/or federal. Generally, we may not disclose such information unless you consent in writing, the disclosure is allowed by a court order, or in limited and regulated other circumstances. You may revoke an authorization at any time, except to the extent we have already relied on the authorization and taken action. Once you authorize us to release your health information, we cannot guarantee that the recipient we gave the information to is obligated to protect and will not further disclose your information.

Your Health Information Rights. You have the following rights regarding your health information. To exercise any of the rights below, please contact us to obtain the proper forms. You have the right to:

Ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. You must make a written request to restrict the use or disclosure of your information. A Bloom Healthcare representative can provide a form for you to use. Please note that while we will try to honor your request, we are not required to agree to any restriction other than with respect to certain disclosures to health plans as further described in this notice.
Request that we not send health information to health plans in certain cases if the health information is about a health care item or service for which you or a person on your behalf has paid us in full. You must make this request, either verbally or in writing, at the time you submit or call in your order.
Request confidential communications. You have the right to ask us to communicate health information to you using alternative means or at alternative locations. Such requests must be in writing. A Bloom Healthcare representative can provide a form for you to use.
Request an amendment to your health information. You may request that your health record be amended if you believe that the health information we have about you is incomplete or incorrect. Requests to amend your health information must be in writing. A Bloom Healthcare representative can provide a form for you to use.
See and obtain a copy of certain of your health information maintained by us, such as your medical records and billing records. You can also request that we provide a copy of your information to a third party that you name. You must make a written request to inspect and obtain a copy of your health information. A Bloom Healthcare representative can provide a form for you to use.
Receive an accounting of disclosures of your health information. You have the right to obtain a list of instances in which we have disclosed your health information, except in certain instances. Your request must be in writing. A Bloom representative can provide a form for you to use.
To request a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you can still request additional paper copies of this Notice. You may also view and/or print a copy of this Notice at our website, https://uat.bloomhealthcare.com.
Receive a notification in writing of any breach of your unsecured health information without unreasonable delay, but in any event, no later than 60 days after we discover the breach.
If we agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment.

Complaints and Contact Information

You may complain to Bloom Healthcare and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. If you have any questions about this Notice or our privacy practices please contact us at https://bloomhealthcare.com/contact/. For complaints, please contact us at (303) 993-1330.

This Notice is effective July 29, 2019

I have reviewed and agree to the Bloom Healthcare Privacy Statement (click to review)

Is the patient signing on their own behalf?*

Yes

No

Print Name:

Beneficiary's representative/caregiver:

Print Name

Date:*

I agree to allow Bloom Healthcare to be my CCM Medicare provider:*

Yes

No

Authorization to Release Information and Authorization to Bill*

By initialing 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:
- 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 (12600 W Colfax Ave, Suite B-200 Lakewood, CO 80215). Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

I have reviewed and agree to the Bloom Healthcare Authorization to Release Information and Authorization to Bill Policy

Phone

This field is for validation purposes and should be left unchanged.

Bloom healthcare

New patient registration

Or alternatively, you can download the registration forms:

To enroll into Bloom’s CCM (Chronic Care Management) program, use the following link:

New Patient Registration

Patient Info

(303) 993-1330

(303) 647-3647

12600 W Colfax Ave, Suite B-200