Consents & Policies
Last Updated 09/01/2025
Role of BridgeCare Medical in Your Care
BridgeCare Medical provides physician-led transitional care services, including evaluation, medical management, and coordination of services such as home health. BridgeCare Medical does not replace a primary care provider and is not intended to provide continuous, long-term primary care services. Services are episodic and based on medical necessity, typically during periods of transition such as after hospital or rehabilitation discharge. While BridgeCare Medical may assist in coordinating care with other providers or agencies, BridgeCare Medical is not responsible for the actions, availability, or performance of third-party providers.
What to Expect if You Choose BridgeCare Medical
If a patient decides to receive medical services from BridgeCare Medical, the patient can expect the following: • The patient's first visit will be conducted via video conferencing, so the patient does not need to leave their home. • BridgeCare Medical will begin services as promptly as possible, often as soon as home care is scheduled. • BridgeCare Medical doctors will be available by phone for refills, referrals, home health questions, and other care-related concerns. • BridgeCare Medical doctors will provide dedicated post-discharge resources when appropriate. • The patient's supervising and signing doctor will be the Medical Director of BridgeCare Medical, Dr. Harshini Jayasuriya, MD, NPI: 1043507833. • Dr. Jayasuriya holds a license in all states where BridgeCare Medical operates.
HIPAA POLICY & NOTICE OF PRIVACY PRACTICES
HIPAA POLICY – RETRIEVAL OF MEDICAL RECORDS Purpose This policy outlines how BridgeCare Medical retrieves medical records from other providers and databases in compliance with HIPAA regulations. Permissible Retrieval Under HIPAA BridgeCare Medical may retrieve medical records without patient authorization for: • Treatment – providing or coordinating care • Payment – billing and reimbursement • Healthcare Operations – quality improvement, training, and management Minimum Necessary Standard BridgeCare Medical will limit retrieved information to only what is necessary for the intended purpose. Patient Notification and Consent • Patients are informed of these practices through the Notice of Privacy Practices • Additional consent will be obtained when required Record Retrieval Procedures From Other Providers • Requests are made in compliance with HIPAA and provider policies • Only necessary information is requested • Secure methods (fax, secure email) are used From Health Information Exchanges and Authorized Medical Record Systems • Access is limited to authorized personnel • Used only for treatment, payment, or operations • Protected by security safeguards Patient Access Rights Patients may: • Request access to their records • Request disclosures Requests must be submitted in writing and will be fulfilled via secure communication methods. Compliance and Training All staff are trained in HIPAA compliance. Regular audits are conducted to ensure adherence. Contact Information BridgeCare Medical 120 N. Washington Ave, Suite 300 Lansing, MI 48933 Phone: 517-258-0344 Email: contact@bridgecaremed.org ──────────────────────────────────────── HIPAA POLICY – DISCLOSURE OF MEDICAL RECORDS General Rule BridgeCare Medical may disclose Protected Health Information (PHI) without authorization for: • Treatment • Payment • Healthcare operations Minimum Necessary Standard Disclosures are limited to the minimum necessary information. Patient Requests Patients may request access or disclosure of PHI: • Requests must be in writing • Disclosures are provided securely Additional Permitted Disclosures BridgeCare Medical may disclose PHI for: • Public health reporting • Health oversight activities • Legal proceedings • Law enforcement • Coroners and medical examiners • Organ donation • Threat prevention • Government functions • Workers' compensation Revocation of Authorization Under HIPAA, authorization is not required for treatment, payment, and operations (TPO). Therefore, revocation does not apply to these uses. Compliance All personnel are trained and audited for HIPAA compliance. Contact BridgeCare Medical Compliance 120 N. Washington Ave, Suite 300 ──────────────────────────────────────── NOTICE OF PRIVACY PRACTICES Patient Rights Patients have the right to: • Access your medical records • Request corrections • Request confidential communication • Limit sharing • Receive a disclosure log • Appoint a representative • File complaints Patient Choices BridgeCare Medical may use patient information to: • Treat patients • Operate the practice • Bill for services • Address public health concerns • Comply with legal requirements Examples are provided throughout to help clarify these uses. BridgeCare Medical Responsibilities BridgeCare Medical is required to: • Protect patient health information • Notify patients of breaches • Follow this privacy notice • Obtain written authorization for uses not described Reporting Concerns Patients may contact BridgeCare Medical or the Office for Civil Rights (OCR) without fear of retaliation. Changes to This Notice BridgeCare Medical may update this notice at any time. Updated versions will apply to all information on file and will be available upon request and online. Final Acknowledgment This notice is provided to patients electronically and/or in person. The clinical provider will review key elements and obtain acknowledgment prior to the first clinical visit.
Choice
Patients have the freedom to choose any doctor or medical practice that best meets the patient's needs. This includes choosing who manages the patient's medication refills, home health orders, post-discharge care needs, and other physician-related services. Choosing a doctor helps ensure that prescriptions, orders, and care coordination are handled efficiently and that needed services can begin as promptly as possible. Patients may choose any doctor who is available to meet with the patient. This may be the patient's regular doctor, another doctor the patient already knows, or any doctor or medical practice of the patient's choosing. Med Clubs, PLLC d/b/a BridgeCare Medical ("BridgeCare Medical") is one option that provides doctors who can assist with medication refills, home health supervision and management, discharge-related needs, and care coordination. BridgeCare Medical has prepared this document to explain the medical services it provides. Any statements below regarding BridgeCare Medical's services are made by BridgeCare Medical. This information is provided to help patients make an informed decision about physician services related to home health or discharge care. Patients have the right to choose a different doctor or medical practice at any time. Patients also have the option to pursue treatment options outside of home health or discharge services. Patients will not be treated differently by any home health agency or by BridgeCare Medical if a patient chooses another doctor or medical group. If a patient has questions about treatment alternatives, the patient should discuss them with the patient's doctor. If a patient has questions about this form, the patient should discuss them with the individual or entity that provided it.
Home Health
If a patient is eligible for home health services, the patient has the right to choose which home health agency the patient wishes to work with. BridgeCare Medical will work closely with the patient's selected home health agency to support smooth, coordinated, and uninterrupted care. However, BridgeCare Medical cannot guarantee the quality, availability, staffing, timeliness, or specific services provided by the home health agency a patient chooses, as BridgeCare Medical does not control the operations of independent home health agencies. Not all patients qualify for home health services, and some patients may qualify initially but later no longer meet eligibility criteria. Eligibility may depend on medical necessity, insurance requirements, homebound status, skilled need, physician documentation, and other payer-specific rules. BridgeCare Medical conducts an independent assessment of each patient's needs to determine the most appropriate services and whether home health services appear medically appropriate. BridgeCare Medical does not guarantee approval, initiation, or continuation of home health services. Final determination is subject to payer requirements, eligibility criteria, and agency acceptance.
Treatment Consent and Scope
The patient authorizes evaluation and treatment by BridgeCare Medical, including shared medical appointments, telemedicine services, and any related services, products, or goods that BridgeCare Medical may make available to the patient and that the patient requests from time to time, and that BridgeCare Medical agrees to provide at its discretion (collectively, "Services"). This includes the use of audio and video technology for diagnosis, communication, monitoring, and patient safety. BridgeCare Medical providers and staff may adjust the patient's care plan and Services as medically appropriate to support the patient's health and well-being. By signing this Patient Agreement and/or receiving any Services, the patient voluntarily consents to and authorizes BridgeCare Medical to provide such Services. The patient acknowledges that the patient has been informed, to the patient's satisfaction, about: • The purpose of the Services • The procedures involved • Potential contraindications • Possible benefits and risks The patient accepts these and consents to receiving Services prior to their delivery. The patient agrees to inform BridgeCare Medical of any medical conditions, contraindications, medications, adverse effects, or changes in the patient's health status during the entire time the patient is receiving Services. The patient understands that the patient may ask questions at any time regarding the patient's care or Services. Patients may withdraw consent at any time; however, doing so may limit or prevent BridgeCare Medical from providing services. Information Accuracy and Confidentiality The patient is responsible for providing accurate and complete medical history, medication lists, and other relevant information. BridgeCare Medical is not responsible for clinical decisions impacted by incomplete or inaccurate information provided by the patient or third parties. The patient understands that the practice of medicine is not an exact science and that outcomes cannot be guaranteed. BridgeCare Medical makes no promises or guarantees regarding results, outcomes, or prognosis. If a referral to a specialist is needed: • The patient will be consulted regarding the patient's preferences • BridgeCare Medical may assist in coordinating the referral • The patient may choose the patient's own specialist • If the patient does not have a preference, BridgeCare Medical may recommend an independent provider
CONSENT FOR TELEHEALTH
What is Telehealth? Telehealth allows patients to receive care from a healthcare provider (such as a physician or nurse practitioner) remotely using technology, including phone, tablet, or computer, without needing to travel to a clinic or hospital. How Telehealth is Used • Patients may communicate with the provider using video and/or audio technology • Video is typically used so the patient and the provider can see each other • In some cases, audio-only visits may be used depending on clinical needs and insurance coverage • Services are provided only when the patient is physically located in a state where the provider is licensed at the time of the visit. Patients are responsible for accurately reporting their location at the time of service. • Electronic communications, including text and email, are not intended for urgent or emergency medical needs. Benefits of Telehealth • No need to travel to a clinic or hospital • Faster access to care • Reduced exposure to illness from others • Improved convenience for patients with mobility or transportation challenges Potential Downsides of Telehealth • It may feel different from an in-person visit • Physical examination may be limited • There is a possibility of incomplete assessment compared to in-person care • The provider may determine that an in-person visit is necessary • Technical issues (internet, device failure, etc.) may interrupt the visit • BridgeCare Medical is not responsible for delays, interruptions, or inability to provide services due to technical failures, including but not limited to internet connectivity issues, device malfunction, or third-party platform outages Privacy During Telehealth Visits • Patients should be in a private location whenever possible • The provider will inform the patient if anyone else is present during the visit • Telehealth systems are designed to protect patient privacy, but there is a small risk of unauthorized access or interception Office Visits vs. Telehealth Visits • Most visits are conducted via telehealth unless otherwise indicated • Patients may request an in-person visit when available • Patients may stop telehealth at any time Costs of Telehealth • Costs depend on the patient's insurance plan • Telehealth visits are typically billed similarly to office visits • Charges will not exceed the cost of an equivalent in-person visit What Signing Means Agreeing to this consent is optional. By signing, the patient indicates that the patient understands and agrees to receive telehealth services as described.
CLINIC PRACTICES AND POLICIES
Non-Discrimination BridgeCare Medical is committed to providing care in an inclusive, respectful environment free from discrimination based on race, color, national origin, age, disability, sex, or any other protected characteristic, in accordance with applicable federal and state laws. Form Completion For efficiency and accuracy, BridgeCare Medical encourages you to complete forms during a scheduled video visit. A $50 fee may apply for form completion outside of a visit. This includes: • FMLA forms • Disability paperwork • Workers' compensation forms • School forms • Other administrative patient requests Termination of Care BridgeCare Medical reserves the right to terminate the patient-provider relationship under certain circumstances, including but not limited to: • Non-adherence to treatment recommendations • Repeated missed appointments • Policy violations • Nonpayment • Verbal abuse or inappropriate behavior All terminations will be conducted in compliance with applicable legal and professional standards. Upon termination of services, patients are responsible for securing ongoing care with an appropriate provider. BridgeCare Medical may provide limited transitional support but is not responsible for long-term care continuity after discharge from services. Appointments To support efficient care for all patients, patients agree to: • Complete all intake paperwork prior to the appointment • Upload or email any relevant medical documentation • Log into the telemedicine platform at least 5 minutes before the scheduled time If a patient anticipates delays or cannot attend an appointment, the patient agrees to notify BridgeCare Medical as soon as possible. Cancellation Policy • Appointments must be canceled at least 24 hours in advance • Late cancellations or missed appointments may result in a $50 fee Late Arrivals and No-Shows • Arriving more than 20 minutes late may result in cancellation • Visits may still end at the originally scheduled time • After 3 cancellations within 30 days, BridgeCare Medical may discharge the patient • After 2 no-shows within 30 days, BridgeCare Medical may cancel future appointments and discharge the patient Emergency Services BridgeCare Medical does not provide emergency care. If a patient experiences a medical emergency or believes one may occur: • Call 911 immediately, or • Go to the nearest emergency room BridgeCare Medical does not provide real-time monitoring or guaranteed immediate response to patient communications. Response times may vary based on clinical volume and urgency.
Financial Policy
FINANCIAL RESPONSIBILITY Patients are responsible for all charges related to services provided by BridgeCare Medical, whether covered by insurance or paid out-of-pocket. Payments, including co-pays, are due at the time services are rendered. INSURANCE PARTICIPATION BridgeCare Medical may or may not be in-network with your insurance plan. - If out-of-network, patients are responsible for payment and may not be eligible for reimbursement from Medicare or Medicaid - If in-network, patients assign all insurance payments directly to BridgeCare Medical PAYMENT AND REIMBURSEMENT - Verification of insurance benefits is not a guarantee of coverage or payment. Final determination of coverage is made by the patient's insurance plan. - Patients must provide accurate information for billing - Any payments received directly from insurance must be forwarded to BridgeCare Medical - Deductibles and co-pays are the patient's responsibility and cannot be waived UNDERSTANDING INSURANCE Patients are responsible for understanding: - Your coverage - Deductibles - Co-pays - Referral or authorization requirements If a claim is denied or partially paid, patients are responsible for the remaining balance. COLLECTIONS AND PAYMENT PLANS Unpaid balances may: - Be referred to collections - Result in additional charges Payment plans may be considered for financial hardship. IMPACT ON TREATMENT Failure to make payments may result in delays, suspension, or discontinuation of care. PATIENTS WITHOUT ACTIVE INSURANCE AT TIME OF SCHEDULING BridgeCare Medical understands that insurance activation may take time. To begin care promptly: - A one-time $150 fee is charged prior to the first visit if no active insurance is on file - This covers the first month of service - Once insurance is verified, BridgeCare Medical will bill your insurance accordingly.
General Legal Disclaimers
DISCLAIMERS AND LIMITATIONS OF LIABILITY BridgeCare Medical provides services without any express or implied warranties. To the fullest extent permitted by law, BridgeCare Medical disclaims all warranties, including those implied by law, regarding the Services provided. BridgeCare Medical shall not be liable for any consequential, incidental, indirect, exemplary, special, or punitive damages. This includes, but is not limited to: - Loss of use - Lost wages or income - Loss of revenue or profit - Business interruption - Loss of information BridgeCare Medical's total liability, if any, is limited to the total amount paid by the patient for the specific services at issue. In the event of a claim, BridgeCare Medical's sole obligation, at its discretion, will be either: - A refund of amounts paid, or - Re-provision of services (retreatment) RELEASE AND INDEMNIFICATION Patients agree to release and hold harmless BridgeCare Medical, its affiliates, providers, employees, and contractors from any claims, liabilities, losses, damages, costs, or injuries arising out of or related to the Services provided. This includes claims arising from: - Negligence - Errors or omissions - Other acts or failures to act This release applies to both known and unknown claims and remains in effect even after termination of services. Patients further agree to indemnify and defend BridgeCare Medical against any third-party claims arising from the patient's actions or failure to comply with this agreement. DISPUTE RESOLUTION This agreement is governed by the laws of the State of Michigan. Except for: - Collection-related matters, and - Claims seeking injunctive relief all disputes will be resolved through binding arbitration conducted by the American Arbitration Association (AAA) in Michigan. By agreeing to this provision, patients: - Waive the right to a jury trial - Waive participation in class-action lawsuits For matters not subject to arbitration, patients consent to the jurisdiction of Michigan courts. MISCELLANEOUS - BridgeCare Medical is not responsible for delays or service interruptions caused by events beyond its control - This agreement supersedes all prior agreements related to its subject matter - If any provision conflicts with another, this agreement will control - All provisions, except those requiring active service delivery, survive termination - Changes to this agreement must be in writing and signed by BridgeCare Medical - This agreement applies to, and benefits permitted heirs, representatives, successors, and assigns
CONTROLLED SUBSTANCE POLICY
Adherence to Guidelines BridgeCare Medical follows all applicable federal and Michigan state guidelines regarding controlled substances, including opioid prescribing standards. Medications are typically only renewed if they were prescribed at hospital discharge or are clinically appropriate based on provider evaluation. Prescription Limitations • Controlled substances are generally limited to 7-day prescriptions • Total prescribing duration will not exceed 4 weeks unless clinically justified • Extensions beyond this timeframe require an in-person evaluation Provider Discretion All prescribing decisions, including medication type, quantity, and monitoring, are made at the sole discretion of the provider to ensure patient safety. Chronic Pain Management Patients requiring ongoing pain management beyond four weeks must establish care with an in-person provider for continued treatment. Patient Responsibilities Patients agree to: • Disclose all medications currently being taken • Follow treatment recommendations • Use only the designated pharmacy • Maintain scheduled appointments Restrictions • Early refills are not permitted • Lost or stolen medications will not be replaced without a police report Monitoring Patients receiving controlled substances for more than two weeks may be required to: • Undergo drug screening • Participate in monitoring programs Risks and Acknowledgments Patients acknowledge: • The risk of developing substance use disorders • The risk of overdose • The legal consequences of misuse or distribution of medications Safe Disposal Patients will be provided with guidance on safe disposal of unused medications to prevent misuse. Note: This policy will be reviewed again with the patient if a controlled substance is prescribed.
BridgeCare Medical — Consents & Policies
Last updated: 03/30/2026
Choice
As a patient, you have the freedom to select any doctor who best meets your needs. This choice empowers you to determine who manages your medication refills and home health orders.
You may choose any doctor available to meet with you. This may be your regular doctor or any doctor of your choosing. BridgeCare Medical is one option that provides doctors who can manage medication refills, home health supervision, and discharge needs.
You have the right to choose a different doctor or medical practice at any time. You may also pursue treatment options outside of home health or discharge services.
What to Expect
- Your first visit will be conducted via video from your home
- Services begin as soon as possible
- Providers are available for refills, referrals, and questions
- Post-discharge support is provided
Supervising Physician: Dr. Harshini Jayasuriya, MD
Home Health Coordination
If eligible, you may choose your home health agency. BridgeCare coordinates care but does not guarantee third-party services.
Consent to Treat
I authorize evaluation and treatment by BridgeCare, including telemedicine and related services.
- I voluntarily consent to treatment
- I understand risks and benefits
- I have had the opportunity to ask questions
- I will provide accurate medical information
Medical outcomes cannot be guaranteed.
Telehealth Consent
Telehealth allows you to meet with your provider remotely using phone, tablet, or computer.
Benefits
- No travel required
- Reduced exposure to illness
Limitations
- Limited physical exam
- Possible technical issues
Privacy
- You should be in a private location
- There is a small risk of data interruption
You may stop telehealth at any time.
Clinic Policies
Appointments
- Complete paperwork before visits
- Log in 5 minutes early
- 24-hour cancellation required
- $50 fee for missed appointments
Emergency Care
BridgeCare does not provide emergency services. Call 911 or go to the nearest ER.
Financial Policy
- You are responsible for all charges
- Out-of-network services require direct payment
- Late fees apply after 90 days
- Unpaid balances may be sent to collections
Non-insured patients: Payment is required prior to initial services.
Controlled Substance Policy
- Follows Michigan guidelines
- Short-term prescriptions only
- No early refills
- Drug testing may be required
- Chronic pain requires in-person care
HIPAA & Privacy
BridgeCare may use and share records for treatment, payment, and operations.
Your Rights
- Access your records
- Request corrections
- Request disclosures
Legal Disclaimer
- No guarantees of outcomes
- Liability limited to amounts paid
- Disputes handled via arbitration in Michigan
Signature Acknowledgment
By signing, you confirm you understand and agree to all policies listed above.