Membership Pricing

Your Care, Made Affordable

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. No documentation is required — we trust you.

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

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address

Preferred pronouns

How did you hear about Bloom Health?

Step 1b

Household Members

Please list all adults in your household who will be enrolling. Each person will be contacted individually to complete their own membership agreement after approval.

Member 2

First Name

Last Name

Email Address

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.

Household size *

Annual household income *

Employment / income situation

Do you currently have health insurance?

Note: Bloom Health does not bill insurance. Our membership fee covers primary care visits. Having insurance does not affect sliding scale eligibility.

Why we ask: DPC membership replaces insurance for primary care costs — for many patients, the sliding scale rate is significantly less than a typical insurance copay or deductible. We want to make sure this program goes to those who genuinely need financial support.

Step 3

Tell Us a Little About Your Situation

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

Which best describes why you're applying for the sliding scale rate?

My income makes standard DPC membership unaffordable I'm currently uninsured and need accessible primary care I'm a student with limited income I'm on disability or unable to work full-time I'm in a transitional period (job loss, relocation, etc.) Other financial hardship

What health concerns are you hoping to address at Bloom Health? This is not a commitment — just helps us prepare to serve you.

Is there anything else you'd like us to know?

Step 4

Agreement & Acknowledgment

I confirm that the information I've provided about my household income is honest and accurate to the best of my knowledge. I understand the sliding scale rate is $55/month with a $55 one-time registration fee (individual), and that each enrolling member is responsible for their own monthly fee. I understand this is a month-to-month membership billed monthly. I can cancel at any time with 30 days notice. I understand that sliding scale spots are limited and that approval is not guaranteed. Bloom Health will contact me to discuss next steps. I understand that Bloom Health is a direct primary care practice and is not a substitute for health insurance coverage. I agree to notify Bloom Health if my financial situation changes significantly, so that spots remain available to those in need.

Electronic Signature

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

Full Legal Name *

Today's Date *

Questions? Call us at (352) 580-6573 or email [email protected]

Sliding Scale Membership
Application

Your Care, Made Affordable

Who is this application for?

Personal Information

Household Members

Household & Income

Tell Us a Little About Your Situation

Agreement & Acknowledgment

Electronic Signature

Application Received

Woman-owned, nurse practitioner-led

Inclusive Primary Care

Inclusivity Statement

Sliding Scale MembershipApplication

Your Care, Made Affordable

Who is this application for?

Personal Information

Household Members

Household & Income

Tell Us a Little About Your Situation

Agreement & Acknowledgment

Electronic Signature

Application Received

Woman-owned, nurse practitioner-led

Inclusive Primary Care

Inclusivity Statement

Sliding Scale Membership
Application