Office Policies Form

Thank you for choosing Bridgepoint for your health care needs. As part of your relationship with Bridgepoint, a clear comprehension of our office policies is important so you will understand office procedures, individual responsibilities, financial liability, and the extent and limits of various forms of communications. These polices may be updated over time for which you will be notified. Current office policies are also listed on the website.

  • Appointments can be requested by telephone, portal, or email.
  • Appointments will be confirmed by text/email ahead of time; however, it is the patient’s/guardian’s responsibility to keep track of the appointment to avoid charges for missed or cancelled appointments.
  • Appointments can be cancelled by the provider if the patient is more than 10 minutes late to their appointment. The patient will be subject to the full charges.
Cancellations/Missed Appointments(Required)
  • If an appointment is cancelled less than 2 business days in advance, or missed, the patient/guardian is subject to a no-show fee of $50.
  • After 2 missed appointments within 1 calendar year, the patient will be sent a warning letter regarding office policy.
  • After 3 missed appointments within 1 calendar year, patient will be at risk of being dismissed from the practice.
Charges & Payments(Required)
  • Payment is due at the time of service. CASH or CREDIT CARD (Visa & MasterCard) are the only acceptable forms of payment.
  • Current Cash Rates:
    • New Patient Evaluation:
      Medical Doctor – $400, Physician Assistants & Nurse Practitioner’s – $275
    • Follow-up Visit:
      Medical Doctor – $225, Physician Assistants & Nurse Practitioner’s – $175
  • Rates are subject to change, but the patient/guardian will be notified by the time of scheduling an appointment.
  • The adult accompanying a minor to a session, even if they are not the legal guardian, will be responsible for payment at the time of the service. Arrangements for advance payments can be made.
  • There will be charges for services provided outside of individual appointments. Please look at the Medical Records Request Form and Provider Fee Form.
Medication Refills(Required)
  • Medications will be refilled at each appointment if it is clinically appropriate so that patient will not run out before their next appointment
  • If due to a missed appointment a patient runs out of medications,
    • the non-controlled medication(s) will be refilled one time only (if deemed clinically appropriate by the treating psychiatrist) until next available appointment.
    • the controlled medication(s) will be refilled one time only for up to 30 days (if deemed clinically appropriate by treating psychiatrist) and an appointment must be made within that timeframe to be evaluated in person.
  • Medication Refills will not be performed in the following cases:
    • After office hours
    • Over the weekend
    • During Holidays
    • For Individuals who repeatedly miss appointments
    • If there is suspicion of abuse of medications
Prior Authorizations(Required)
  • Bridgepoint will provide services for Prior Authorizations if needed.
Forensic Policy(Required)
  • Should providers from Bridgepoint be subpoenaed to appear in court or provide testimony via phone, Consultation services are billed at $900 per hour, in half hour increments (1 hour minimum). The amount is to be paid to Bridgepoint prior to services rendered.
  • Risk of using Email: Bridgepoint offers patients the opportunity to communicate via a patient portal that is secure. We strongly encourage use of the patient portal for communication. However, you may also email Bridgepoint at Do not send emails to any other email address you may come across. Transmitting patient information by unsecured e-mail has a number of risks that patients should consider. These include, but are not limited to, the following risks:
    • E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
    • E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
    • E-mail senders can easily misaddress an e-mail.
    • E-mail is easier to falsify than handwritten or signed documents.
    • Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
    • E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
    • E-mail can be used to introduce viruses into computer systems.
    • E-mail can be used as evidence in court.
  • We cannot guarantee the security and confidentiality of e-mail communication and will not be liable for improper disclosure of confidential information that is not caused by our unintentional misconduct.
  • Providers may forward e-mails internally (within Bridgepoint) to staff and agents as necessary for treatment and other handling needs. We will not, however, forward e-mails to independent third parties.
  • All e-mails to or from the patient concerning diagnosis or treatment will be made part of the patient’s medical record. Because they are a part of the medical record, other individuals authorized to access the medical record, such as staff and counselors, will have access to those e-mails.
  • The patient/guardian is responsible for protecting his/her password or other means of access the patient portal. Bridgepoint is not liable for breaches of confidentially caused by the patient/guardian or any third party.
  • Bridgepoint shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
    • It is the patient’s/guardian’s responsibility to follow up and/or schedule an appointment if warranted.
  • Please call with any urgent, clinical questions. We will return you call within 48 hours but earlier if possible.
  • Please do NOT leave a message in case of emergencies. See emergency procedures below.
  • Text messaging is NOT an acceptable form of communication
  • In the course of therapy with a child, it is important for Bridgepoint to gain his/her trust for therapy to work. Although legally a guardian has access to a child’s record, please understand that in order for a child to build this trust, material revealed in one to one sessions should be maintained confidential between the provider and the child. However, if it is determined that a child is doing things or is exposed to things that are life endangering, the guardian will be notified.
  • All information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is required by law.
    • Disclosure may be required in the following circumstances:
      • Where there is a reasonable suspicion of child abuse or elder adult physical abuse
      • Where there is a reasonable suspicion that the patient presents a danger of violence to others, or where the patient is likely to harm him or herself unless protective measures are taken.
      • Pursuant to a legal proceeding.
Emergency Treatment(Required)
  • If for some reason, you cannot reach Bridgepoint directly and patient/guardian deems there is an emergency, they are directed to call 911 or go to the nearest emergency room for immediate services. You may also call the Georgia Crisis and Access Line at 1-800-715-4225 or the National Suicide Hotline at 1-800-273-8255 (1-800-SUICIDE).
Conduct and Dress Code(Required)
  • Patients/guardians are required to abide by the clinic policies.
  • Patients and/or guardians are required to wear appropriate shoes and clothing.
  • Disruptive or aggressive behavior can lead to dismissal from the clinic.
Items Not Allowed(Required)
  • Food and/or beverage is not allowed on office premises.
  • Use of tobacco products, including any e-cigs or vapes, are not allowed on clinic grounds.
  • Weapons or firearms are not allowed on clinic grounds.
Consent to Provide Treatment(Required)
  • Bridgepoint may provide treatment in the form of medication therapy, psychotherapy, laboratory testing, diagnostic procedures, and other appropriate alternative treatments.
  • You have the right to:
    • Be informed of and participate in the selection of the treatment methods and plan
    • Receive a copy of this and all consents as well as request your records at any time
    • Withdraw any consent at any time


I acknowledge that I have read and fully understand Bridgepoint office policies. I understand and have been explained the financial policies includes charges and payment options. I understand the risks associated with the communication of e-mail and telephone between providers and myself. I have been explained the limitations of Bridgepoint availability to the client and emergency procedures. Any questions I may have were asked and answered.

MM slash DD slash YYYY