• PATIENT INFORMATION FORM

    PATIENT INFORMATION FORM

  • Welcome to BridgeCare Medical.

    This guided form allows us to prepare for the patient’s care in advance by collecting key information and reviewing eligibility. It takes just a few minutes to complete. Once submitted, our team will call the patient directly to coordinate next steps.

  • 🟡 SERVICES REQUESTED*

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

  • ⚠️ VISIT & CARE REQUIREMENTS

  • 1. Will the patient be able to complete a video visit at their 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 & CARE INFORMATION

  • B. MOST RECENT FACILITY STAY (Past 30 Days) The information below helps us determine eligibility for different services.
  • 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 delay scheduling or result in patient responsibility.

  • PRIMARY INSURANCE

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

  • SECONDARY INSURANCE (if applicable)

  • Date of Birth (Policy Holder):
     - -

  • AUTO INSURANCE (if related to injury or accident)

  • Format: (000) 000-0000.
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  • 🟡 NEXT STEPS

  • Once the intake and insurance forms are received, BridgeCare Medical will:

  •  

    1. Contact the patient
    by phone and text      		 2. Schedule the
    initial appointment    		 3. Begin coordination of care

     

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

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

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