Sliding Scale Application

Sliding scale rates are income-based and subject to availability. Apply as an individual or together as a household (2–4 adults). Your honest self-assessment helps us ensure this program reaches those who need it most.

Bloom Health — Sliding Scale Membership Application
Please note: Bloom Health is currently in-network with Cigna, United Healthcare, FL Medicaid, FL Medicare, and Tricare. If you have one of these plans, you are not eligible for the sliding scale program — please contact us directly to discuss your care options.

Your Care, Made Affordable

Standard Rate
$75/mo
Per adult
+ $100 one-time registration
Sliding Scale — Individual
$55/mo
Per adult
+ $55 one-time registration
Sliding Scale — Household
$50/mo
Per adult (2–4 people)
+ $45 registration per person
Before You Begin

Who is this application for?

Select whether you are applying as an individual or as a household (2–4 adults living together). Each person in a household application will need to be listed below.

Individual
Applying for myself only
$55/mo
$55 one-time registration
Household
Applying for 2–4 adults together
$50/mo per person
$45 registration per person
Step 1

Personal Information

Step 2

Household & Income

Please answer to the best of your ability. This information stays confidential and is used only to determine eligibility. No documentation required.

Why we ask: Our sliding scale program is reserved for patients without access to in-network coverage. If you are uninsured, underinsured, or carry a plan we do not accept, we want to make sure cost is never a barrier to your care.
Step 3

Tell Us a Little About Your Situation

Optional but helpful. This gives us context and helps our team serve you better.

This is not a commitment — just helps us prepare to serve you.
Step 4

Agreement & Acknowledgment

By signing below, I confirm that: my household income information is accurate; I understand the sliding scale rate is $55/month with a $55 one-time registration fee (individual); membership is month-to-month and can be cancelled with 30 days notice; sliding scale spots are limited and approval is not guaranteed; Bloom Health is a direct primary care practice and is not a substitute for health insurance; and I agree to notify Bloom Health if my financial situation changes significantly.

Electronic Signature

By typing your full name below and submitting this form, you are providing your electronic signature and agreeing to all of the above.

Questions? Call us at (352) 580-6573 or email naomi@heybloomhealth.com

🌿

Application Received

Thank you for applying to Bloom Health's sliding scale program. We'll review your application and reach out within 2–3 business days to discuss next steps.

In the meantime, feel free to call us at (352) 580-6573 with any questions.