Card on File Consent Form

Effective January 1, 2024, Bridgepoint is requiring all patients to keep a credit card on file. Your signature in this form is to authorize charges to your credit card through our epayment system via eclinicalworks for services rendered. Your card information will be stored securely in eclinicalworks and charged only when there is a balance on your account. These charges will appear on your bank/credit card statement as Bridgepoint. You have the right to request a paper copy of this document.

I authorize Bridgepoint, LLC to charge my credit card. I also agree that my credit card will be charged for any additional fees that I incur, including late cancellation/no shows for visits with my therapist or psychiatric provider, form fees, urine drug screens, and provider letters. I authorize Bridgepoint to charge my credit card the same day these fees are incurred. The fees are listed below:

  • Missed/late cancelled therapy session $140.00
  • Missed late cancelled follow-up psychiatry appointment $75.00
  • Urine drug screen $35.00
  • Form fee/FMLA/Disability (per packet) $50.00
  • Provider letters $40.00

I understand that if I have a balance with Bridgepoint after my insurance company processes my claim, including deductible, coinsurance, and copays, the office will run my credit card on file to settle this balance. Bridgepoint will not charge the card on file more than $200.00 per month without my permission. If the balance is larger than $200.00, the card on file will be run on the 15th day of the month until the balance is paid in full. If the 15th day of the month falls on a weekend, the credit card will be charged the following business day. The billing office will send a text, as a courtesy, before they run my credit card. Please notify the office if you have a change in phone number. I understand that it is my responsibility to contact the office and update my card on file or notify the billing office if I need to make other payment arrangements before the 15th of the month. Bridgepoint will not refund processed payments.

I understand that this authorization will remain in effect as long as I am a patient at Bridgepoint Clinic, LLC. I agree to notify Bridgepoint, LLC of any changes in my account information. I understand that I may not be able to start or continue services without an active card on file.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

Please check the following boxes below to initial each line:
Check Below
By checking the boxes above you certify that you are the person completing this form and that the check represents your initials, and further certify that by checking these boxes you understand and consent to the content therein.
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