Service Payment Form

BridgeCare Service Payment Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Health Company (Optional)
Assigned or Requesting
Patient Phone Number*
Patient Email

Services*

Service

New Patient Visit

Detailed Consultation with Prescription and Equipment Orders

$175.00 Mode

New Patient Visit with Home Health Management

Includes Home Health Management Services x 60 days (Video Required) Note: If the patient does not qualify for home health services, the payer will be reimbursed $75 back to card provided.

$275.00

Follow Up Visit

As-needed visit for symptoms, refills, FMLA, and other urgent care needs for current patients

$50.00 Mode

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

E-mail Receipt (Optional)
example@example.com
Payer Contact Number (Optional)
Format: (000) 000-0000.
Additional Notes (Optional)
Should be Empty:

BridgeCare Service Payment Form

Payment Methods