When your insurance is verified, the benefits given are not a guarantee of payment. Insurance will decide whether the item, visit, procedure, etc. is deemed medically necessary and will only do so after the claim has been submitted. It is your responsibility as the patient to call your insurance for all questions or disagreements you may have with the policy benefits related to our office. You have the right to ask for benefit coverage before any procedure is performed in the office that may cost you an additional charge. The prices given are only an estimation of benefit coverage. If the insurance denies a claim and the cost exhausts all appeal efforts, then you as the patient will be responsible for the cost. If you have any questions or concerns regarding coverage, feel free to contact the office and your insurance company.

• Copay and/or all non-covered services are due at the begining of your service. This fee cannot be billed to you at a later date. Patients who have not completed payment prior to their appointment may be subject to cancellation (late cancel fee included), and the provider may be unable to proceed with the visit.

• There will be a $50 charge for all disability forms and FMLA forms, and a minimum fee of $25 for all medical records or letters. Please allow two weeks for the completion of these forms, records, or letters. All forms or requests must be given to the front office staff directly.

• • We require a 24-hour notice for cancelling or rescheduling an appointment, or a $25 fee will be applied to the patient’s account. This also applies to “no show” appointments. There will be a $35 fee for any returned checks along with any associated bank fees.

I have read the above patient responsibilities and agree to comply, and I accept the responsibilities for any payment that becomes due as outlined above.

I acknowledge and understand that all telephone conversations and text message communications with Bridge Family Practice may be monitored and/or recorded. This includes, but is not limited to, calls regarding appointment scheduling, clinical follow-ups, billing inquiries, and any service-related discussions. These recordings are conducted for purposes such as quality assurance, staff training, accurate documentation, and to ensure compliance with applicable laws and clinic policies.

By signing below, I provide my consent for such recordings and understand that this authorization will remain in effect for all future interactions unless I revoke it in writing. I also acknowledge that standard message and data rates may apply based on my mobile service provider. I confirm that the phone number I have provided belongs to me and is accurate, and I agree to notify the clinic if my contact information changes.

Additionally, I am aware that although the clinic takes reasonable measures to protect my privacy, text messaging is not considered a secure method of communication and may be accessible to others who have access to my phone or mobile device. I understand that I may opt out of receiving text messages at any time by replying STOP, and that I may revoke my consent for recordings by submitting a written request to the clinic.