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:
Complete this form so we can assist with your mental health journey.