• PATIENT INTAKE AND CONSENT FORM

    PATIENT INTAKE AND CONSENT FORM

  • Welcome to BridgeCare Medical.

     

    This form allows us to prepare for your care in advance by collecting key information, completing consents, and scheduling your visit. It takes just a few minutes to complete, and your appointment will be reserved at the end.



  • 🔵 SERVICES REQUESTED

  • Core Services (Start Here)*
  • Additional Services (Eligibility-Based)

  • ⚠️ VISIT & CARE REQUIREMENTS

  • 1. Will you be able to complete a video visit at your appointment time? Note, we can help coordinate if needed.*

  • 🔵 PATIENT INFORMATION

  • Date of Birth*
     - -
  • Sex at Birth*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 🔵 CLINICAL AND CARE INFORMATION

    ThIs information below helps us determine eligibility for different services.
  • B. MOST RECENT FACILITY STAY IN PAST 30 DAYS (if applicable)
  • Discharge Date (or expected discharge)
     - -

  • 🔵 INSURANCE & REFERRAL INFORMATION

  • Please complete all applicable sections.

  • Accurate insurance information is required for proper billing. Incomplete or incorrect information may result in patient responsible bills.

  • PRIMARY INSURANCE

  • Date of Birth (Policy Holder):*
     - -

  • SECONDARY INSURANCE (if applicable)

  • Date of Birth (Policy Holder):
     - -

  • AUTO INSURANCE (if related to injury or accident)

  • Important

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    • Accurate insurance information is required for proper billing.
    • Incomplete or incorrect information may delay scheduling or result in patient responsibility.

  • Thank you for choosing BridgeCare Medical. We look forward to helping you.

    (517) 258-0344 | (517) 879-0374 | contact@bridgecaremed.org | bridgecaremed.org

  • 🔵 PATIENT CONSENT & AGREEMENT

  • PATIENT INFORMATION

  • Date of Birth:*
     - -
  • Today's Date:*
     - -
  • By signing below, I agree to the key terms outlined in this document—an abbreviated summary of important policies and consents. Full policies are available at bridgecaremed.org.

  • CARE & TELEHEALTH CONSENT

    • I agree to receive care from BridgeCare Medical, including by phone or video.
    • Telehealth has limitations and may require in-person evaluation.
    • Technical issues (e.g., connectivity/platform failure) may require rescheduling.
    • I may stop care at any time, but this may limit services.
    • I understand I must be physically located in a state where the provider is licensed at the time of the visit.

  • CONTROLLED MEDICATIONS

    • BridgeCare does not prescribe chronic controlled substances as routine medication refills.
    • Short-term refills (≤3 weeks) may be considered after inpatient discharges (hospital, SAR, or LTACH) at provider discretion.

  • INFORMATION USE & CARE COORDINATION

    • BridgeCare may share and obtain medical information for my care.
    • This includes communication with insurance, home health agencies, and other providers.
    • I authorize BridgeCare to obtain and review prior medical records as needed.
    • Information may be released if required by law or court order.

  • HOME HEALTH COORDINATION

    • I have the right to choose my home health provider.
    • BridgeCare will honor my preference or continue with the referring agency unless I request a change.
    • A list of preferred agencies is available upon request.
    • Services must meet Medicare/CMS eligibility requirements, including required evaluations and medical necessity.
    • Final acceptance for home health services is subject to insurance eligibility criteria.

  • FINANCIAL RESPONSIBILITY

    • Insurance will be billed, but coverage is not guaranteed.
    • Insurance coverage is for video calls (synchronous telehealth) only.
    • Audio-only phone calls are not covered by insurance and have an out-of-pocket cost.
    • I am responsible for verifying my benefits and providing accurate information.
    • Incorrect or incomplete information may result in denied claims and patient responsibility.
    • Copays are typically billed after the visit.
    • A $15 non-refundable chart preparation fee applies to every new patient. This fee covers expedited insurance verification and chart preparation. The fee will be billed to the patient after the visit, along with any insurance-determined copay.
    • Any balance not covered by insurance is my responsibility.

  • SERVICE LIMITS

  • ASSIGNMENT OF BENEFITS

    • I authorize payment of medical benefits directly to BridgeCare Medical for services rendered.
    • BridgeCare is not an emergency service—call 911 for emergencies.
    • No continuous monitoring or emergency response services are provided.
    • BridgeCare is on a long term primary care service—we do not offer full panel of preventive services.
    • As with all health related care, no guarantees can be made regarding outcomes of evaluations or care. BridgeCare holds to the highest standards in practice of evidence based medicine.

  • ADDITIONAL LEGAL AGREEMENTS

    • I may be asked to verify my identity with a government-issued ID.
    • I understand I have the right to refuse or withdraw consent at any time, though this may limit care.
    • I understand that care decisions are based on medical necessity and regulatory requirements.

  • COMMUNICATION CONSENT (TEXT & EMAIL)

  • By signing below, I agree to receive text message and email communications related to my care, including appointment reminders, follow-up information, and billing notifications. Text messaging is expected. To opt out of text messages, I must contact the BridgeCare Medical office. Opting out may limit certain telehealth services.

  • STANDARDS OF CARE & PROFESSIONAL PRACTICE

  • BridgeCare Medical provides care in accordance with accepted standards of medical practice, ethics, and evidence-based medicine. We comply with all applicable federal and state laws, including HIPAA privacy and security standards. Care decisions are based on medical necessity, patient safety, and best available evidence.

  • ACKNOWLEDGMENT

  • This list above is an abbreviated summary of key elements of the full policies and consents. Full policies and consents are available at bridgecaremed.org*

  • SIGNATURE (REQUIRED)

  • Date of Birth:*
     - -
  • Date:*
     - -
  • By signing, I agree to the terms outlined in this document and the full policies and consents referenced above.

  • Phone: (517) 258-0344  |  Fax: (517) 879-0374  |  contact@bridgecaremed.org  bridgecaremed.org

  • 🔵 Reserve Your Appointment

  • Please select a convenient appointment time from the calendar below. 

    If coordination with your home health team is needed to assist with your video visit, your appointment time may be adjusted to ensure proper support. 

  • Appointment Times
  • Should be Empty: