Annual Telemedicine Consent

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.
• 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.