Forms & Policies
New Clients
If you’re new to Bloom Women’s Wellness, welcome! Your welcome letter and intake form are listed below, as is a client referral form for providers referring new clients to us.
Welcome Letter
When you begin therapy with Bloom Women’s Wellness, you will receive a welcome document from your therapist. If you no longer have your document or if you’re interested in our process, please feel free to re-download.
Intake Form
The information shared in the intake form lets your provider know more about you. If your form is related to medication management, please email the completed form to the email at the bottom of the form. If your form is related to therapy only, please send the completed form to your therapist’s email directly. Find your therapist’s contact information here.
Client Referral Form
This form is to be completed by a provider referring a client to Bloom Women’s Wellness. Please email the completed form to the email at the bottom of the form.
Release Document
For an outside release of information (ROI), please send this completed document to the email address at the top of the form.
Medication Policies & Reminders
Medication Questions
For questions regarding the status of a refill, medication-related clinical concerns, or general questions about your medications, please email us by clicking the button below. Please allow up to two work days (48 hours) for a response. If there is a medical emergency, please dial 911.
Lab Info & Requests
If you or your provider requests lab testing, orders will be submitted electronically. Please allow two work days (48 hours) for orders to be submitted. To schedule your testing appointment, please visit Quest Scheduling. For lab-related questions, please email us by clicking the button below. Your provider will review the results with you at your next appointment.
Refills & Prior Authorization
Do not contact the pharmacy for refills. Instead, please email or call our registered nurse, Michelle Ridgeway, directly at (515) 776-7859. You may also be directed to Michelle through our main line at (515) 499-4959 (select “pharmacies”). Please allow up to 72 hours for all requests to be honored and up to 5 business days for prior authorization requests.
Medication Tips
Download our PDF of helpful tips to help you plan for your medication appointments.
Appointment Policies
Scheduling Appointments
New client paperwork must be completed 48 hours prior to the appointment or the visit will be automatically cancelled.
Cancelling or Rescheduling
If you need to cancel or reschedule an appointment with your provider, please email us.
Follow-Up Appointments
You may schedule follow-up appointments through the booking portal. We recommend scheduling two appointments at a time, with 4-6 weeks between them unless other recommendations have been made by your provider. If you would like notifications and reminders for your appointments, please select this option through the portal.
Cancellation Fees
Things happen and we understand. When you need to cancel, we ask for notice so that we may reach out to other clients who may be able to take your spot.
For Counseling Appointments
We ask for a 24-hour (one full business day) cancellation notice ahead of your scheduled counseling appointment. If this notice is not given and you fail to make your appointment, a $185 fee will be charged to your account.
For Medication Appointments
We ask for a 48-hour (two full business days) cancellation notice ahead of your scheduled medication or psychology appointment. Excessive cancellations and/or no-shows/late cancellations will result in future sessions being cancelled and termination of therapy and medication management services, and possibly a restriction from future bookings. If the balance on the account exceeds $100, you will not be able to schedule another appointment until it is taken care of and other arrangements are made.
Late cancellation or first no-show: $75
Second no-show: $150
Third no-show: $250
Billing, Insurance, & Records
For questions about medical records or billing, including service fees, please contact Mitch Sweet.
For questions about insurance appeals and denials, please contact Chad Gagnier.
Reproductive Health & Substance Use Privacy Protections
(HIPAA 2025-2026 Updates)
New Federal Privacy Protections
Effective February 16, 2026, federal law requires additional protections for certain types of sensitive health information. In compliance with updated HIPAA regulations and applicable federal law, Bloom Women’s Wellness provides the following notices:
Reproductive Health Information
We are prohibited from using or disclosing reproductive health information for purposes of investigating or imposing liability on a person, provider, or third party for seeking, obtaining, providing, or facilitating lawful reproductive health care.
Reproductive health information includes, but is not limited to, information related to:
- Pregnancy, pregnancy loss, and postpartum care
- Fertility and infertility services
- Contraception
- Abortion or abortion-related services
- Perinatal and maternal mental health care
We will not disclose reproductive health information for law enforcement, judicial, or administrative proceedings when such use or disclosure is prohibited by federal law. When required, we may request a valid attestation confirming that a requested use or disclosure is permitted under HIPAA.
Substance Use Disorder Records (42 CFR Part 2)
Certain records related to the diagnosis, treatment, or referral for treatment of a substance use disorder (SUD) are protected by 42 CFR Part 2, a federal law that provides additional confidentiality protections beyond HIPAA. These records:
- Cannot be disclosed without your specific written consent, except as permitted by law
- Are protected even within healthcare systems
- May not be re-disclosed without authorization
If you receive services that fall under these protections, your records will be handled in strict compliance with 42 CFR Part 2 and applicable HIPAA regulations.
Your Rights
You have the right to:
- Request restrictions on certain uses or disclosures of your health information
- Receive an accounting of disclosures when required by law
- Revoke authorizations as permitted
These enhanced protections do not change your access to care, treatment options, or your ability to receive services at Bloom.
Contact Bloom Women's Wellness
Payments Accepted
We accept Wellmark Blue Cross Blue Shield, Anthem, Midland’s Choice, Cigna, Health Partners, and private pay clients. We believe that mental health care should be accessible and we’re happy to work with you on a sliding fee scale.