Thank you for choosing Bridge Family practice as your healthcare provider. The medical services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By signing below and/or by receiving medical services from Bridge Family Practice, you agree:

 

Insurance & Coverage

• Insurance verification is performed as a courtesy; however, quoted benefits are not a guarantee of payment. All pricing provided is an estimation only. If a claim is denied and all appeal options are exhausted, you will be responsible for the full cost of the service.

• Please be advised that our office is not in network with Medicare or Medicaid plans. As a result, all patients are considered self-pay at the time of service. This status may also limit our ability to provide referrals, authorizations, or certain forms of treatment that require insurance participation.

• To ensure insurance coverage for your visit, our office must be listed as your designated Primary Care Provider (PCP) on all HMO and POS insurance plans. If you are seen without updating your PCP to reflect our office, your insurance will not cover the visit, and you will be responsible for the full cost of services rendered. Please verify and update your PCP designation prior to your appointment.

• Final coverage decisions are made by your insurance provider after a claim is submitted and reviewed for medical necessity. It is your responsibility to contact your insurance provider directly with any questions or disputes regarding coverage or benefits.

• You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply: (i) your health plan determines that the services you received at Bridge Family Practice are not medically necessary and/or not covered by your insurance plan (common reasons being: Weight Loss, Travel, Work Related Services, ED, etc.); (ii) your health plan coverage has lapsed or expired at the time you receive services at Bridge Family Practice; or (iii) you have chosen not to use your health plan coverage. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly.

 

Payment Expectations

• Copays and fees for non-covered services are due at the time of service. These cannot be billed later.

• Whether or not you have insurance or are self-pay, payment of any account balance is due within sixty (60) days of receipt of your billing statement date. If any balance on your account is over ninety (90) days past due, there may be delays regarding further appointment scheduling and refills until balance is cleared.

• You must notify us of any errors or objections to the billing statement within thirty (30) days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact our office staff to address the problem or to discuss a workable solution.

• Patients who have not completed payment prior to their appointment may be subject to cancellation (including late cancellation fees), and the provider may be unable to proceed with the visit.

• Payment for all telemedicine visits is due prior to your scheduled appointment time. The provider will not initiate the call until the required copay or visit fee has been collected. If payment is not received in advance, the appointment will be marked as a no-show, and a $25 no-show fee will apply.

 

Forms & Documentation Fees

• All Disability and FMLA forms requested by patients are subject to a $50 administrative fee per form, in addition to the applicable copay for the visit. This amount is subject to change based on the complexity of the paperwork. Please ensure all required sections by patients are completed prior to submission.

• Requests for medical records, letters, or documentation are subject to a minimum administrative fee of $25. Additional charges may apply depending on the complexity or volume of the request.

• Please allow up to two weeks for completion. All requests must be submitted directly to front office staff.

 

Appointment Changes & Returned Checks

• We require a minimum of 24 hours’ notice for all appointment cancellations or rescheduling requests. Failure to provide timely notice will result in a $25 fee, including for missed or “no-show” in-person or telemedicine appointments. This helps us maintain availability and respect the time of our providers and patients.

• As a courtesy, our office sends out text message reminders for upcoming appointments. However, these reminders are not guaranteed and should not be relied upon as your sole method of tracking appointment dates and times.

• It is the patient’s responsibility to know and remember their scheduled appointments. Failure to attend a scheduled appointment—regardless of receiving a reminder—will result in a “no-show” fee of $25.

• As such, no-show appointment fees will not be waived or disputed unless we have a verifiable cancellation notice on record from the patient—submitted via phone call, voicemail, or written communication at least 24 hours prior to the scheduled appointment.

• Repeated no-shows may result in limitations on future scheduling until the balance has been cleared.

• All returned checks are subject to a $35 administrative fee, plus any applicable bank charges incurred during processing. Please ensure sufficient funds are available prior to submitting payment to avoid delays or additional fees.

 

Consent & Acknowledgment

By signing below, I acknowledge and affirm the following:

• I have carefully read and fully understood the financial policies outlined in this document, including but not limited to payment expectations, insurance requirements, cancellation procedures, documentation fees, and telemedicine protocols.

• I have been given the opportunity to ask questions, seek clarification, and receive satisfactory answers regarding any aspect of these policies prior to signing.

• I understand that these policies are in place to ensure transparent communication, operational efficiency, and equitable treatment for all patients.

• I agree to comply with all financial terms and conditions as stated, including timely payment of copays, administrative fees, and any charges resulting from missed appointments, returned checks, or non-covered services.

• I understand that failure to adhere to these policies may result in denied services, additional fees, or limitations in care coordination, including referrals and documentation support.

My signature below confirms my voluntary consent to abide by these policies and my understanding of the financial responsibilities associated with receiving care at this facility.

At Bridge Family Practice, we are committed to creating a safe, respectful, and professional environment for all patients, staff, and providers. To uphold this standard, we ask that all individuals adhere to the following expectations:

Mutual Respect Commitment
• I agree to treat all providers, staff, and fellow patients with courtesy, dignity, and professionalism. I understand that disrespectful, aggressive, threatening, or inappropriate behavior will not be tolerated and may result in dismissal from the practice.
• I acknowledge that Bridge Family Practice staff is held to the same standards, and I have the right to expect respectful, compassionate, and professional care at all times. Communication & Conduct
• I will communicate honestly and respectfully, whether in person, by phone, or electronically. That verbal abuse, harassment, or discriminatory language is grounds for immediate termination of services. I agree to follow clinic policies and procedures designed to protect the safety and well-being of all individuals.

Consent & Acknowledgment
By signing below, I confirm that:
• I have read and understood the expectations outlined in this form, and have had the opportunity to ask questions and receive clarification. I consent to comply

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.

Bridge Family Practice is pleased to offer telemedicine services as a convenient and secure way to access medical care. To ensure clarity, fairness, and continuity of care, we ask that all patients review and acknowledge the following terms prior to scheduling or participating in a telemedicine visit:
 
Telemedicine Consent
I understand and agree that:
 
• Telemedicine involves the use of electronic communications via phone call to enable real-time interaction between myself and a licensed healthcare provider for the purpose of diagnosis, treatment, follow-up, and patient education.
• Telemedicine services are held to the same standards of care, confidentiality, and documentation as in-person visits.
• I have the right to ask questions and receive information regarding the nature of the telemedicine visit, including potential risks, limitations, and alternatives.
• Please note that telemedicine coverage is subject to change based on evolving decisions by government agencies and insurance providers. While our office continues to offer telemedicine appointments, coverage may vary depending on your plan and carrier. In some cases, telemedicine visits may be considered self-pay.
• Bridge Family Practice records all incoming and outgoing phone calls for quality assurance, training, documentation, and compliance purposes.
• By continuing with services and communications, you acknowledge and consent to the recording of all telephone interactions with our office and providers.
• We expect all patient phone calls with providers to reflect courtesy, professionalism, and mutual respect. This includes tone, language, and conduct throughout the conversation. Our providers are equally held to high standards of respectful communication, and we welcome feedback to ensure accountability on both sides.
• I may withdraw my consent to telemedicine services at any time without affecting my right to future care or treatment.
 
 
Payment Policy
To ensure timely and uninterrupted care, I acknowledge the following financial terms:
 
• All copays, visit fees, and applicable charges must be paid in full prior to the scheduled telemedicine appointment time.
• The provider will not initiate the call until payment has been received and confirmed by the office.
• If payment is not received prior to the appointment, the visit will be considered a missed appointment (“no-show”), and a $25 no-show fee will be charged to my account.
• I understand that this policy is in place to protect provider time, reduce scheduling disruptions, and maintain equitable access to care for all patients.

Acknowledgment
By signing below, I confirm that:
 
• I have read and understood the terms outlined in this Telemedicine Consent & Payment Agreement.
• I have had the opportunity to ask questions and receive clarification regarding telemedicine services and payment expectations.
• I agree to comply with all scheduling, payment, and conduct policies associated with telemedicine visits at Bridge Family Practice.
• I understand that failure to comply may result in delayed care, additional fees, or limitations in future scheduling.