Financial Policy and Payment Agreement

FINANCIAL POLICY AND PAYMENT AGREEMENT

Direct Pay Virtual Clinic

SECTION 1: DIRECT PAY MODEL — HOW WE WORK

1.1 What Is a Direct Pay Clinic?

Direct Pay Virtual Clinic operates exclusively as a direct-pay (cash-pay) healthcare practice. This means we do not participate in any health insurance network, do not bill insurance carriers on your behalf, and do not accept direct payment from any private insurance company, Medicare, Medicaid, MinnesotaCare, or any other third-party payer.

Instead, you pay the Clinic directly for services at transparent, pre-disclosed rates. This model is authorized under Minnesota law governing direct primary care agreements (Minn. Stat. § 62J.84) and allows us to offer straightforward, transparent pricing without the administrative overhead of insurance billing.

1.2 Why Direct Pay?

The direct pay model benefits patients in the following ways:

•       Transparent, upfront pricing — you always know what you will pay before your appointment

•       No surprise bills from the Clinic — the price you are quoted is the price you pay

•       No deductibles, copays, coinsurance, or prior authorization requirements from the Clinic

•       Faster, more efficient appointments without insurance-related administrative delays

•       Potential eligibility for Health Savings Account (HSA) or Flexible Spending Account (FSA) reimbursement

1.3 Direct Pay and Your Insurance

Having health insurance does not disqualify you from using Direct Pay Virtual Clinic. However, you will pay us directly and will not be able to use your insurance to cover our fees at the time of service. You may, however:

•       Request a superbill (itemized receipt with diagnosis and procedure codes) for submission to your private insurance carrier for potential out-of-network reimbursement — see Section 4 for details

•       Use funds from an HSA or FSA to pay for our services, subject to IRS eligibility rules — see Section 5 for details

Please note: Services from Direct Pay Virtual Clinic are generally NOT reimbursable by Medicare or Medicaid. Patients who are Medicare or Medicaid beneficiaries who nonetheless receive services from the Clinic do so on a private-pay basis and should be aware that seeking reimbursement from these programs may implicate federal law.

SECTION 2: FEES, PRICING, AND FEE SCHEDULE

2.1 Current Fee Schedule

Our current fee schedule is posted on our website at directpayvirtualclinic.com. All fees are stated in U.S. Dollars and are subject to change. The fee schedule in effect at the time of your appointment will apply to that appointment. You will be informed of applicable fees before your appointment is confirmed.

A Good Faith Estimate of the expected cost of your specific scheduled services will be provided to you in writing before each appointment, in accordance with the No Surprises Act (45 C.F.R. § 149.610). Please review your Good Faith Estimate carefully before your appointment.

2.2 Fee Schedule Summary

The following table summarizes our current service categories. Specific pricing is available on our website. Fees are subject to change with notice.

 

Service Category	Description	Fee
New Patient Visit	Comprehensive initial telehealth consultation (approx. 30–45 min)	See website
Established Patient Visit — Standard	Follow-up or acute care telehealth visit (approx. 15–20 min)	See website
Established Patient Visit — Extended	Complex or extended follow-up visit (approx. 30–40 min)	See website
Telehealth Consultation	Focused consultation on a specific clinical question	See website
Lab Order / Requisition	Order only — lab fees billed separately by laboratory	$0 (order only)
Imaging Order / Referral	Order only — imaging fees billed separately by imaging facility	$0 (order only)
Prescription Issuance	Included in visit fee where clinically appropriate	Included in visit
Medical Records / Superbill	Standard records request; fee may apply for extensive requests	See Section 6
No-Show / Late Cancellation Fee	Appointment missed without 24-hour notice — see Section 7	See Section 7

 

2.3 Price Changes

Direct Pay Virtual Clinic reserves the right to modify its fee schedule at any time. Updated fees will be posted on our website and will apply to appointments scheduled on or after the effective date of the change. Patients who have already received a Good Faith Estimate for a scheduled appointment will be notified of any fee changes affecting that appointment prior to the appointment date, and an updated Good Faith Estimate will be provided.

SECTION 3: PAYMENT TERMS AND ACCEPTED METHODS

3.1 Payment Due at Time of Service

Payment in full is due at the time of scheduling your appointment or at the time of your appointment, as specified during the booking process. The Clinic will not provide services until payment has been confirmed or a valid payment method has been authorized. Services are not provided on credit or deferred payment unless a specific payment plan has been arranged in writing in advance.

3.2 Accepted Payment Methods

Direct Pay Virtual Clinic accepts the following forms of payment:

•       Major credit cards: Visa, Mastercard, American Express, Discover

•       Debit cards with a Visa or Mastercard logo

•       Health Savings Account (HSA) cards

•       Flexible Spending Account (FSA) cards

•       Such other payment methods as may be made available on our website from time to time

All payment transactions are processed through a secure, PCI-DSS compliant third-party payment processor. The Clinic does not store your complete credit card number on its systems. By providing a payment method, you authorize the Clinic to charge the applicable fee to that payment method.

3.3 Payment Authorization

By providing a payment method and scheduling an appointment, you authorize Direct Pay Virtual Clinic to charge the fees associated with your scheduled service(s) to the payment method provided. You represent that you are authorized to use the payment method provided and that the information you provide is accurate and complete.

For recurring patients, the Clinic may, with your authorization, retain your payment information on file for future appointments. You may withdraw authorization for the retention of your payment information at any time by contacting us in writing.

3.4 Failed or Declined Payments

If your payment is declined or fails for any reason, your appointment will not be confirmed and services will not be provided until payment is successfully processed. The Clinic will notify you of a failed payment and allow you a reasonable opportunity to provide an alternative payment method. Repeated failed payments may result in a requirement to prepay before future appointments are scheduled.

SECTION 4: SUPERBILLS AND INSURANCE REIMBURSEMENT

4.1 Availability of Superbills

Upon written request, Direct Pay Virtual Clinic will provide you with a superbill — an itemized receipt that includes your diagnosis code(s) (ICD-10-CM), procedure code(s) (CPT), provider information including NPI (1912770066), date of service, and the amount paid. You may submit this superbill to your private health insurance carrier for potential out-of-network reimbursement.

Superbill requests should be submitted to info@directpayvirtualclinic.org within ninety (90) days of the date of service. Superbills for services older than one (1) year may not be available.

4.2 No Guarantee of Reimbursement

You are solely responsible for:

•       Determining your plan's out-of-network benefits before seeking care

•       Submitting the superbill to your insurance carrier in a timely manner

•       Following up with your insurance carrier regarding the status of your claim

•       Paying any balance not reimbursed by your insurance carrier

The Clinic will not communicate directly with your insurance carrier, appeal claim denials on your behalf, or adjust its fees based on insurance reimbursement determinations.

4.3 Medicare and Medicaid

Direct Pay Virtual Clinic does not participate in Medicare or Medicaid. Services provided by our Clinic are generally not eligible for Medicare or Medicaid reimbursement when obtained from a non-participating provider on a private-pay basis. Patients who are Medicare or Medicaid beneficiaries acknowledge this limitation when using our services.

If you are a Medicare beneficiary, please be aware that applicable federal regulations govern your ability to pay privately for services that Medicare would otherwise cover. The Clinic will provide information regarding your rights under applicable Medicare private contract requirements upon request.

SECTION 5: HEALTH SAVINGS ACCOUNTS AND FLEXIBLE SPENDING ACCOUNTS

5.1 HSA and FSA Eligibility

Fees paid to Direct Pay Virtual Clinic for medical services may be eligible for reimbursement from a Health Savings Account (HSA) or Flexible Spending Account (FSA), subject to IRS regulations governing qualified medical expenses (IRS Publication 502) and the terms of your individual account.

Generally, fees for medical consultations, diagnosis, and treatment are considered qualified medical expenses under IRS § 213(d). However, eligibility depends on your specific account type, plan terms, and the nature of the services received.

5.2 HSA Card Payments

You may use an HSA debit card to pay for services directly at the time of service. If your HSA card is declined, you are responsible for providing an alternative payment method. The Clinic will provide a receipt that you may use for HSA recordkeeping purposes.

5.3 Patient Responsibility

You are solely responsible for determining the eligibility of specific services for HSA/FSA reimbursement and for compliance with all IRS regulations governing your account. Direct Pay Virtual Clinic is not a tax advisor and does not provide tax or benefits advice. Please consult your account administrator or a qualified tax professional with questions about HSA/FSA eligibility.

SECTION 6: MEDICAL RECORDS AND ADMINISTRATIVE FEES

6.1 Medical Records Requests

You have the right to receive copies of your health records as described in our Notice of Privacy Practices and in accordance with HIPAA (45 C.F.R. § 164.524) and Minn. Stat. § 144.292. The Clinic may charge a reasonable, cost-based fee for the preparation and provision of copies of medical records, as permitted by applicable law.

No fee will be charged for:

•       Records provided directly to the patient for use in their own ongoing care

•       Records provided to another treating provider for continuity of care purposes

•       The first copy of records provided following a request under HIPAA

A fee may be charged for:

•       Extensive records requests requiring significant staff time to compile

•       Requests for records in a specific format not routinely maintained by the Clinic

•       Expedited records requests (where available)

Any applicable fee will be disclosed to you before records are prepared and released. You will not be charged without prior notice and consent.

6.2 Superbills and Administrative Documents

Standard superbills for recent visits (within 90 days) are provided at no charge. A reasonable administrative fee may apply for superbills requested for older visits or for extensive administrative documentation requests. Fees will be disclosed in advance.

SECTION 7: CANCELLATION, RESCHEDULING, AND NO-SHOW POLICY

7.1 Cancellation and Rescheduling

We understand that circumstances change. If you need to cancel or reschedule your appointment, please notify us at least twenty-four (24) hours before your scheduled appointment time through the website booking system or by emailing info@directpayvirtualclinic.org.

Appointments cancelled with twenty-four (24) or more hours notice will receive a full refund or credit, at your option. Appointments cancelled with less than twenty-four (24) hours notice, or missed without prior notice (no-shows), may be subject to the cancellation fee described in Section 7.2.

7.2 Cancellation and No-Show Fees

The following fees may apply for late cancellations and no-shows:

 

Situation	Fee	Applies To
Cancellation with less than 24 hours notice	See current fee schedule	Non-member appointments only
No-show (no notice, missed appointment)	See current fee schedule	All appointments
Clinic-initiated cancellation or rescheduling	No fee — full refund	All appointments

 

Current cancellation and no-show fee amounts are posted on our website. The Clinic reserves the right to waive cancellation or no-show fees at its sole discretion in cases of documented emergency or extenuating circumstances. Waiver requests must be submitted in writing to info@directpayvirtualclinic.org within seven (7) days of the missed appointment.

Patients with three (3) or more no-shows within a twelve (12) month period may be required to prepay the full visit fee at the time of scheduling for future appointments.

7.3 Clinic-Initiated Cancellation

In the event the Clinic must cancel or reschedule your appointment due to provider illness, technical failure, force majeure, or other circumstances beyond our control, you will receive a full refund of any fees paid or a rescheduled appointment at your option. The Clinic will make reasonable efforts to provide as much advance notice as possible of any clinic-initiated cancellation.

7.4 Technical Issues

If a telehealth appointment cannot be completed due to a technical failure attributable solely to the Clinic's platform or equipment, the appointment will be rescheduled at no additional charge, or a full refund will be issued at your option. If technical issues are attributable to your device, internet connection, or environment, the Clinic's standard cancellation policy will apply.

7.5 Membership Cancellation Policy

Direct Pay Virtual Clinic offers membership plans that are billed on a recurring monthly basis. The following terms govern the cancellation of a membership:

•       You may cancel your membership at any time by providing written notice to the Clinic at info@directpayvirtualclinic.org or through your patient account portal.

•       No refunds will be issued for the current monthly billing period in which cancellation is requested, regardless of the date of cancellation within that billing cycle.

•       Upon cancellation, you will retain full access to all membership benefits and services through the end of the current paid billing period.

•       Your membership will not renew for the following billing period, and no further charges will be assessed after the current billing period ends.

•       Cancellation requests must be received at least two (2) business days before the next scheduled billing date to prevent the issuance of the next billing cycle charge. Cancellation requests received less than two (2) business days before a billing date may result in one additional charge, which will be refunded if the cancellation request was timely submitted.

•       Membership cancellation does not affect your right to continue using the Clinic as a non-member patient for future appointments at applicable non-member rates.

Example: If your membership billing cycle renews on the 15th of each month and you cancel on the 8th, you will not be refunded for the current cycle. You will retain full membership access through the 14th and your membership will not renew on the 15th.

SECTION 8: REFUND POLICY

8.1 Completed Consultations

Fees paid for completed telehealth consultations are generally non-refundable. A consultation is considered "completed" once the Provider has conducted a clinical assessment, regardless of whether a specific diagnosis or prescription results from that assessment.

The Clinic's obligation is to provide a good-faith clinical assessment, not to produce a specific outcome. The absence of a diagnosis, prescription, or treatment recommendation following a consultation does not entitle the patient to a refund.

8.2 Refund Eligibility

A refund or credit may be issued in the following circumstances:

•       The appointment was cancelled by the Clinic (full refund)

•       A material technical failure attributable to the Clinic prevented the completion of the consultation (full refund or rescheduling credit at patient's option)

•       A billing error resulted in an overcharge (refund of the overcharged amount)

•       Other circumstances at the sole discretion of the Clinic

8.3 Refund Process

Approved refunds will be processed to the original payment method within seven (7) to ten (10) business days of approval. Refund requests must be submitted in writing to info@directpayvirtualclinic.org and must include the patient's name, date of service, and reason for the refund request. Refund requests must be submitted within thirty (30) days of the date of service.

8.4 Chargebacks

If you initiate a chargeback or dispute with your credit card issuer or bank for fees that were properly charged under this Financial Policy, the Clinic reserves the right to: (a) dispute the chargeback with documentation of services rendered; (b) terminate the patient-provider relationship; and (c) pursue collection of any amounts owed, including chargeback fees imposed on the Clinic by the payment processor.

We encourage you to contact us directly at info@directpayvirtualclinic.org to resolve any billing concerns before initiating a chargeback.

SECTION 9: THIRD-PARTY SERVICES — LABORATORY, IMAGING, AND PHARMACY

9.1 Separate Billing by Third Parties

When your Provider orders laboratory tests, imaging studies, or other services to be performed by an external provider, those services are billed directly to you by the external provider. Direct Pay Virtual Clinic does not collect, process, or retain any portion of fees charged by third-party laboratories, imaging facilities, pharmacies, or specialist providers.

9.2 Laboratory Services

Laboratory orders issued by Direct Pay Virtual Clinic will be provided to you as a paper or electronic requisition. You are responsible for:

•       Choosing a laboratory that accepts your payment method or insurance (if using insurance for lab services)

•       Scheduling your own laboratory appointment or walk-in visit

•       Paying the laboratory directly for all laboratory fees

•       Requesting a Good Faith Estimate from the laboratory before services are performed, which you are entitled to under the No Surprises Act

The Clinic recommends contacting your chosen laboratory in advance to inquire about pricing. Common options for affordable lab work include national reference labs, hospital outpatient labs, and direct-to-consumer lab services.

9.3 Imaging Services

Imaging orders (X-ray, MRI, CT scan, ultrasound, etc.) issued by Direct Pay Virtual Clinic will be provided to you as a paper or electronic order. You are responsible for:

•       Choosing an imaging facility that accepts your payment method or insurance

•       Scheduling your own imaging appointment

•       Paying the imaging facility directly for all imaging fees

•       Requesting a Good Faith Estimate from the imaging facility before services are performed

The Clinic has no affiliation with any specific imaging facility and does not receive any financial benefit from referrals. You are free to choose any imaging provider and are encouraged to compare prices.

9.4 Pharmacy and Prescription Costs

Prescription costs are set by your pharmacy and the medication manufacturer and are not within the control of Direct Pay Virtual Clinic. The Clinic will transmit prescriptions electronically to your pharmacy of choice at no additional charge. You are responsible for all costs associated with filling prescriptions.

Discount programs such as GoodRx, NeedyMeds, and pharmacy manufacturer assistance programs may be available to reduce prescription costs. The Clinic can provide information about these programs upon request but makes no representations about their availability or benefit for specific medications.

SECTION 10: COLLECTIONS AND OUTSTANDING BALANCES

10.1 Outstanding Balances

In the event that any balance remains unpaid following a service (e.g., due to a returned payment, chargeback, or other billing issue), the Clinic will contact you in writing at the contact information on file. You agree to respond to billing inquiries within fourteen (14) days of receipt.

10.2 Collection Procedures

Unpaid balances that are not resolved within thirty (30) days of written notice may be referred to a third-party collection agency or pursued through appropriate legal channels. You agree to pay all costs of collection, including reasonable attorneys' fees and collection agency fees, if permitted by applicable Minnesota law.

The Clinic complies with the Fair Debt Collection Practices Act (15 U.S.C. § 1692 et seq.) and Minnesota's debt collection statutes (Minn. Stat. Ch. 332) in all collection activities.

10.3 Disputed Charges

If you believe you have been charged incorrectly, please contact us in writing at info@directpayvirtualclinic.org within thirty (30) days of the charge, providing your name, date of service, the amount charged, and the basis for your dispute. We will investigate and respond within fourteen (14) business days. Disputed charges should not be withheld pending investigation unless the dispute is submitted in writing as described above.

SECTION 11: PATIENT ACKNOWLEDGMENT AND AGREEMENT

By signing below, I acknowledge and agree that:

1.     I have read, understand, and agree to the Financial Policy and Payment Agreement of Direct Pay Virtual Clinic in its entirety;

2.     I understand that Direct Pay Virtual Clinic operates on a direct-pay (cash-pay) basis and does not bill insurance on my behalf;

3.     I understand that payment in full is due at the time of service and that services will not be provided without confirmed payment;

4.     I understand that the Clinic's fees are posted on its website and that a Good Faith Estimate will be provided to me before each scheduled appointment;

5.     I understand that laboratory, imaging, pharmacy, and specialist fees are billed separately by independent third-party providers and are my sole responsibility;

6.     I understand the Clinic's cancellation, no-show, and refund policies as described in this document;

7.     I understand that the Clinic makes no representations regarding insurance reimbursement and that I am solely responsible for any insurance claims I choose to submit;

8.     I authorize Direct Pay Virtual Clinic to charge the payment method I provide for applicable services and fees;

9.     I have been given the opportunity to ask questions about this Financial Policy and have had them answered to my satisfaction;

10.   I understand that a copy of this document is available to me upon request.

 

 

Patient Full Name		Date of Birth
Email Address		Phone Number
Preferred Payment Method		Date

 

Patient Full Legal Name (Print): ____________________________________________   Date of Birth: _______________

Patient Signature: __________________________________________________   Date Signed: ___________________

 

If signed on behalf of a minor or legally incapacitated patient:

Representative Full Legal Name (Print): ________________________________   Relationship: ___________________

Representative Signature: __________________________________________________   Date Signed: ___________________

 

 

FOR CLINIC USE ONLY

Document Provided By		Date Provided
Payment Method on File		Verified By

This Financial Policy and Payment Agreement complies with Minn. Stat. § 62J.84 (direct primary care), Minn. Stat. § 62J.81 (price transparency), the No Surprises Act (Pub. L. 116-260), the Fair Debt Collection Practices Act (15 U.S.C. § 1692 et seq.), Minn. Stat. Ch. 332 (Minnesota debt collection), and applicable consumer protection laws. | Direct Pay Virtual Clinic | NPI: 1912770066 | CNP License #24617