Temporary Primary Care Consent
Overview
The goal of BridgeCare Services is to assist patient recovery at home and prevent a return to the hospital once they are at home. To do this, BridgeCare provides temporary primary care services for patients lasting 30 days or more. These services are reserved for patients who reside in Michigan and meet one of the following.
- A patient without a primary care physician to oversee and sign home orders.
- A patient with a primary care physician but they are unable to provide a within 7 days of coming home
- A patient with a primary care physician but the physician is unable/unwilling to sign and/or manage orders.
If a patient has a primary care physician willing to facilitate the transition home, authorize home orders, and manage services, the patient will likely not need BridgeCare.
Services
1. I understand BridgeCare authorizes and manages home nursing, home physical therapy, home health aide, home social work, medication refills, medical equipment orders, IV antibiotic management, wound care, and other medical supply needs.
2. I understand I will not be able to receive BridgeCare services if I do not arrange for my first appointment within 7 days of coming home.
3. I understand a BridgeCare Provider determines the medical needs of all orders and services by reviewing hospital records, rehabilitation notes, and speaking to me.
4. I understand there is no guarantee that BridgeCare will determine medical necessity for any home service, home order, or discharge medication.
5. I understand that if BridgeCare deems a service or order as not medically necessary, but I still want a particular service, I can request to pay out of pocket to a private company providing such services.
6. I understand BridgeCare rarely prescribes controlled substances. However, if a controlled substance is prescribed, it will be a three-day course, and BridgeCare Specialists will review information from the Prescription Drug Monitoring Program in my state of residence.
7. I understand that BridgeCare Specialists Provider’s advice, recommendations, and/or decisions may be based on factors not within the provider's control, including the inability to perform a physical exam or incomplete or inaccurate data provided by the patient.
8. I understand my BridgeCare provider may believe I would be better served by face-to-face services or another form of care and be referred to an appropriate health care provider.
Telehealth
1. I understand in the case of an emergency, I may be instructed to call 911 or go directly to the nearest hospital emergency room.
2. I understand BridgeCare provides all medical services using telehealth (phone, video, data communication). I will not need to leave my home and will not be in the same room as the BridgeCare provider.
3. I understand to start BridgeCare services, I will need access to a working phone or computer to speak to the BridgeCare staff and Providers.
4. I understand if I choose to provide my email, BridgeCare is allowed to email me an appointment and summary of care updates.
Patient Rights
1. I have the right to refuse BridgeCare services at any time.
2. I have the right to withdraw consent to telehealth services or end the telehealth session at any time.
3. I understand BridgeCare Specialists will provide care consistent with the prevailing standards of medical practice.
4. I understand no assurances or guarantees as to the results of treatment can be made.
5. I understand I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by the health care provider(s), together with any available alternatives.
6. I understand BridgeCare holds to the highest level of medical privacy and all existing confidentiality protections that apply to in-person treatment apply to telehealth services. BridgeCare Specialists’ privacy policies can be found online at bridgecarespecialists.com
7. I understand by signing this Consent, I acknowledge I have reviewed and consent to BridgeCare Specialists’ use and disclosure of my health information in accordance with its terms
8. I understand that once my 30-day treatment plan is completed, my care will be transferred to a doctor of my choosing.
9. I understand if my care needs extend beyond 30-days, I can request an extension of services. Extensions are at the discretion of the BridgeCare provider and cannot be guaranteed.
Payment
1. I understand, I am assigning to BridgeCare Specialists all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to BridgeCare Specialists.
2. I understand, if I have health care benefits, BridgeCare Specialists will submit a claim to my insurance.
3. I understand I will pay any required co-payments, co-insurance, and deductibles, as well as charges for services not covered by insurance.
4. I understand I will be billed for all unpaid balances after 90 days deemed by BridgeCare Specialists or my insurer to be my responsibility and agree to pay such amounts in full.
5. I understand BridgeCare Specialists will charge late fees of 1.5% per month on unpaid balances starting 90 days after the first statement.
6. I understand BridgeCare Specialists reserves the right to deny non-emergency services if my account is delinquent.
7. I understand BridgeCare accepts most Michigan Insurances, but I am untimely responsible to ensure services are covered.
For any questions on eligibility or services, call (517)-300-0716 to communicate with a BridgeCare Staff Member. By signing below, I understand I am consenting to BridgeCare Discharge Services and all terms as stated.