Patient Rights and Responsibilities

PATIENT RIGHTS AND RESPONSIBILITIES

Direct Pay Virtual Clinic

INTRODUCTION

Direct Pay Virtual Clinic is committed to providing high-quality, respectful, and transparent healthcare to every patient. As a patient, you are a valued partner in your own care. This document sets forth your rights under Minnesota law and federal law, as well as your responsibilities to the Clinic and to your own health.

The Minnesota Patients' Bill of Rights (Minn. Stat. § 144.651) and related federal laws, including the Health Insurance Portability and Accountability Act (HIPAA, 45 C.F.R. Parts 160 and 164), the Americans with Disabilities Act (ADA, 42 U.S.C. § 12101 et seq.), Section 1557 of the Affordable Care Act (42 U.S.C. § 18116), and other applicable statutes, guarantee each patient a comprehensive set of rights. These rights are not waivable, and no action you take — including signing any consent or agreement — shall be interpreted as a waiver of any right protected by law.

The responsibilities described in this document are not punitive conditions of care. They exist to support your health outcomes, the safety of our Provider, and the effective operation of the Clinic.

PART 1: YOUR RIGHTS AS A PATIENT

1. Right to Respectful, Dignified Care

You have the right to receive courteous, considerate, and respectful care at all times, regardless of your age, race, color, national origin, ethnicity, religion, sex, gender identity, gender expression, sexual orientation, disability, socioeconomic status, insurance status, or any other characteristic protected by applicable state or federal law.

This right is protected under Minn. Stat. § 144.651, Subd. 6; the Americans with Disabilities Act (42 U.S.C. § 12101 et seq.); Section 1557 of the Affordable Care Act (42 U.S.C. § 18116); and Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d). Direct Pay Virtual Clinic does not discriminate in the provision of services on any basis prohibited by law.

2. Right to Informed Consent and Informed Refusal

You have the right to receive complete, accurate, and understandable information about your diagnosis, proposed treatment, alternative treatments, and the risks and benefits of each option, including the option of no treatment. This information will be communicated in language you can understand.

You have the right to participate fully in decisions regarding your care, to ask questions, and to receive honest answers. You have the right to give or withhold informed consent before any treatment, procedure, or prescription is provided, except in emergency circumstances where consent cannot reasonably be obtained.

You have the right to refuse any recommended treatment, medication, or procedure, and to be informed of the medical consequences of that refusal. Exercising your right of refusal will not result in the termination of your care, except where continued care would be clinically inappropriate or unsafe.

This right is protected under Minn. Stat. § 144.651, Subd. 9 and applicable common law principles of informed consent recognized under Minnesota law.

3. Right to Privacy and Confidentiality

You have the right to privacy in your healthcare consultations and in the handling of your protected health information (PHI). All communications, records, and information pertaining to your care are confidential and will not be disclosed without your written authorization, except as permitted or required by HIPAA (45 C.F.R. § 164.502) and the Minnesota Health Records Act (Minn. Stat. § 144.293).

You have the right to conduct your telehealth visit in a private manner, free from unnecessary observation or interruption. You are encouraged to ensure your own environment is private during your appointment.

You have the right to be informed of and to receive a copy of the Clinic's Notice of Privacy Practices, which explains in detail how your health information is used, disclosed, and protected. A copy of the Notice of Privacy Practices is available on our website and upon request.

4. Right to Access Your Health Records

You have the right to inspect, copy, and receive a written summary of your health records maintained by Direct Pay Virtual Clinic, in accordance with HIPAA (45 C.F.R. § 164.524) and Minn. Stat. § 144.292. Requests must be submitted in writing and will be fulfilled within thirty (30) days, or within ten (10) calendar days when records are needed for ongoing care.

You have the right to request amendments to inaccurate or incomplete information in your health records under 45 C.F.R. § 164.526 and Minn. Stat. § 144.2095.

You have the right to request an accounting of disclosures of your health information made by the Clinic other than for treatment, payment, or operations, as provided under 45 C.F.R. § 164.528.

A reasonable, cost-based fee may be charged for copies of records as permitted by applicable law. No fee will be charged for records requested by the patient for personal use in connection with their own ongoing care.

5. Right to Know Your Provider's Identity and Qualifications

You have the right to know the name, professional title, credentials, and licensure status of the healthcare provider delivering your care. Direct Pay Virtual Clinic's services are provided by Megan Lundberg, APRN-FNP, licensed by the Minnesota Board of Nursing (CNP License #2461751, NPI: 1912770066).

You have the right to request information about the Clinic's policies, procedures, and any professional relationships that may affect your care. This right is protected under Minn. Stat. § 144.651, Subd. 8.

6. Right to a Second Opinion and Continuity of Care

You have the right to seek a second opinion from another qualified healthcare provider at any time and at your own expense. The Clinic will not discourage you from seeking a second opinion and will cooperate with the transfer of records as authorized by you.

You have the right to continuity of care and to receive information about follow-up services, referrals, and treatment alternatives. The Clinic will provide clinically appropriate transition assistance, including referrals to in-person providers, when telehealth is insufficient to meet your needs. This right is protected under Minn. Stat. § 144.651, Subd. 13.

7. Right to File Complaints and Grievances Without Retaliation

You have the right to voice concerns, complaints, and grievances about your care or the Clinic's policies without fear of retaliation, discrimination, or adverse impact on your future care. Complaints may be submitted in writing to info@directpayvirtualclinic.org or through the contact form on our website.

If your concern is not resolved to your satisfaction by the Clinic, you have the right to file a complaint with the following regulatory bodies:

•       Minnesota Board of Nursing (APRN practice complaints): www.nursingboard.state.mn.us | (612) 317-3000

•       Minnesota Department of Health (healthcare facility complaints): www.health.state.mn.us | (651) 201-5000

•       U.S. Department of Health and Human Services, Office for Civil Rights (HIPAA, civil rights, nondiscrimination): www.hhs.gov/ocr | 1-800-368-1019

•       Minnesota Attorney General's Office (consumer protection): www.ag.state.mn.us | (651) 296-3353

The Clinic shall not retaliate against any patient for filing a complaint. Retaliation is prohibited under HIPAA (45 C.F.R. § 164.530(g)), Minn. Stat. § 144.298, and applicable civil rights laws.

8. Right to Non-Discriminatory Care

You have the right to receive care without discrimination based on race, color, national origin, sex, age, disability, religion, sexual orientation, gender identity, gender expression, marital status, familial status, public assistance status, or any other characteristic protected by applicable Minnesota or federal law.

This right is protected by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116), Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d), the ADA (42 U.S.C. § 12101 et seq.), and the Minnesota Human Rights Act (Minn. Stat. Ch. 363A).

If you require a reasonable accommodation due to a disability in order to access or participate in our telehealth services, please contact us at info@directpayvirtualclinic.org and we will make every reasonable effort to accommodate your needs.

9. Right to Language Access and Communication Assistance

You have the right to receive care and communications in a language you understand. If you have limited English proficiency or require communication assistance due to a sensory or communication disability, please notify us when scheduling your appointment so that appropriate arrangements can be made. This right is protected under Title VI of the Civil Rights Act (42 U.S.C. § 2000d) and Section 1557 of the Affordable Care Act (42 U.S.C. § 18116).

10. Right to Transparent Financial Information

You have the right to receive a written Good Faith Estimate of expected costs prior to any scheduled appointment, in accordance with the No Surprises Act (Pub. L. 116-260, Div. BB, Title I) and 45 C.F.R. § 149.610. You have the right to receive an itemized bill for all services rendered upon request.

You have the right to full disclosure of the Clinic's direct-pay model, pricing structure, and financial policies before you receive services. This right is further protected under Minn. Stat. § 62J.81 (healthcare price transparency).

You have the right to dispute a bill that exceeds your Good Faith Estimate by $400 or more through the federal Patient-Provider Dispute Resolution process. For details, see our Good Faith Estimate Notice or visit www.cms.gov/nosurprises.

11. Right to Information About Emergency Services

You have the right to be informed that Direct Pay Virtual Clinic does not provide emergency medical services. In the event of a medical emergency, you have the right to be directed to call 911 or go to the nearest hospital emergency department. In the event your Provider identifies signs of a medical emergency during your telehealth visit, they will advise you to seek emergency care immediately and may contact emergency services on your behalf.

If you are experiencing a mental health crisis or thoughts of suicide or self-harm, you have the right to be informed of and referred to crisis resources, including the 988 Suicide and Crisis Lifeline (call or text 988) and the Crisis Text Line (text HOME to 741741).

12. Right to Advance Directives

You have the right to formulate and execute advance directives, including a healthcare directive (living will) and a durable power of attorney for healthcare, as provided under the Minnesota Health Care Directive Act (Minn. Stat. Ch. 145C) and the federal Patient Self-Determination Act (42 U.S.C. § 1395cc(f)). You may request information about advance directives from the Clinic at any time.

While Direct Pay Virtual Clinic does not provide inpatient care, we will note the existence of any advance directives in your health records and will communicate their existence to any provider to whom we refer you.

13. Rights of Minor Patients

Patients who are minors (under age 18) have specific rights under Minnesota law to consent to and control certain health information related to:

•       Sexually transmitted infection (STI) testing and treatment (Minn. Stat. § 144.343)

•       Pregnancy-related care (Minn. Stat. § 144.343)

•       Outpatient mental health treatment in certain circumstances (Minn. Stat. § 144.341)

•       Substance use disorder treatment in certain circumstances (Minn. Stat. § 144.341)

In these specific circumstances, a minor patient's health information may be kept confidential from parents or guardians to the extent required or permitted by Minnesota law. The Clinic will comply with all applicable laws regarding minor patient confidentiality and consent.

For all other services, a parent or legal guardian must provide consent on behalf of a minor patient.

14. Rights of Personal Representatives and Legal Guardians

A legally authorized personal representative, legal guardian, or holder of a durable power of attorney for healthcare has the right to exercise the patient rights described in this document on behalf of a patient who is a minor, who is legally incapacitated, or who has granted such authority. The Clinic reserves the right to verify the legal authority of any representative before acting on their instructions.

PART 2: YOUR RESPONSIBILITIES AS A PATIENT

The following responsibilities are not conditions of receiving care. They are expectations that support your health outcomes and the safe, effective operation of Direct Pay Virtual Clinic. We ask that you fulfill these responsibilities to the best of your ability.

1. Responsibility to Provide Accurate and Complete Information

You are responsible for providing complete, accurate, and truthful information about your health, including your medical history, current medications (including over-the-counter medications, vitamins, and supplements), known allergies and adverse reactions, prior surgeries and hospitalizations, family medical history, and any other information relevant to your care.

You are responsible for notifying the Clinic of any changes to your health status, medications, or contact information before or during your appointment. The Clinic cannot be held responsible for clinical errors arising from inaccurate, incomplete, or withheld information provided by the patient.

2. Responsibility to Participate Actively in Your Care

You are responsible for actively participating in your care, asking questions when you do not understand instructions or recommendations, and communicating your concerns honestly with your Provider. You are responsible for following through with the treatment plan agreed upon during your consultation, to the best of your ability, and for notifying the Clinic if you are unable to do so.

You are responsible for completing all ordered laboratory tests, imaging studies, specialist referrals, or follow-up appointments as recommended by your Provider. Failure to follow through on clinical recommendations may affect the quality and safety of your care.

3. Responsibility to Honor Appointments and Scheduling Policies

You are responsible for scheduling appointments in advance and arriving on time for your telehealth visit. If you need to cancel or reschedule, you are responsible for notifying the Clinic at least twenty-four (24) hours in advance. Repeated no-shows or late cancellations may result in a cancellation fee as described in the Clinic's Terms of Service.

You are responsible for ensuring that your technology (device, camera, microphone, and internet connection) is functioning before your appointment and for being in a private, quiet location during your visit.

You are responsible for confirming that you are physically located within the State of Minnesota at the time of your telehealth appointment.

4. Responsibility to Treat Staff and Providers with Respect

You are responsible for treating the Clinic's Provider and any staff with dignity, courtesy, and respect. Abusive, threatening, harassing, or discriminatory behavior toward the Provider or staff — including via electronic communications — will not be tolerated and may result in discharge from the practice, subject to applicable laws governing patient abandonment and continuity of care.

You are responsible for refraining from making false, defamatory, or misleading statements about the Clinic, its Provider, or its staff in any public forum or review platform.

5. Responsibility to Fulfill Financial Obligations

You are responsible for understanding and agreeing to the Clinic's direct-pay pricing before scheduling an appointment. You are responsible for payment in full at the time of service as described in the Clinic's Financial Policy and Terms of Service.

You are responsible for reviewing your Good Faith Estimate before your appointment and raising any pricing questions or concerns before services are rendered.

You are responsible for all costs associated with laboratory services, imaging services, prescription medications, and specialist consultations that are billed directly by external providers. The Clinic is not responsible for charges from third-party providers.

If you intend to submit a superbill to your health insurance carrier for potential reimbursement, you are responsible for managing that process independently. The Clinic makes no representations about insurance reimbursement.

6. Responsibility Regarding Medications and Prescriptions

You are responsible for taking prescribed medications as directed and for contacting the Clinic promptly if you experience unexpected side effects, adverse reactions, or concerns about a prescribed medication.

You are responsible for disclosing all current medications, supplements, and recreational substance use to your Provider to prevent dangerous drug interactions. You understand that the Clinic does not prescribe controlled substances via telehealth.

You are responsible for obtaining prescription refills through a scheduled follow-up appointment. You acknowledge that the Clinic does not issue prescription refills based on patient request alone, without a clinical encounter.

7. Responsibility to Use Services Honestly and Lawfully

You are responsible for using the Clinic's services only for lawful purposes and in good faith. You must not attempt to obtain medications, prescriptions, referrals, or documentation through misrepresentation, deception, or fraud. Any suspected fraudulent conduct will be reported to the appropriate authorities as required by law.

You are responsible for not recording any telehealth session without the prior written consent of the Provider, as required by Minnesota's two-party consent law (Minn. Stat. § 626A.02).

8. Responsibility to Recognize and Respond to Emergencies

You are responsible for understanding that Direct Pay Virtual Clinic does not provide emergency services, and for calling 911 or going to the nearest emergency room in any medical emergency. You acknowledge that you have been informed of this limitation and accept responsibility for your own actions in an emergency.

You are responsible for having a plan for accessing emergency care if needed during or after a telehealth consultation.

PART 3: ACKNOWLEDGMENT AND SIGNATURE

By signing below, you acknowledge that:

1.     You have received, read, and understand this Patient Rights and Responsibilities document in its entirety;

2.     You have been given the opportunity to ask questions about its contents and have had any questions answered to your satisfaction;

3.     You understand that the rights described in Part 1 are guaranteed to you by Minnesota and federal law and are not waivable;

4.     You agree to fulfill the responsibilities described in Part 2 to the best of your ability;

5.     You have been informed of and understand the Clinic's direct-pay model, its limitations as a telehealth-only practice, and its emergency care policy;

6.     You understand that a copy of this document is available to you upon request at any time;

7.     Nothing in this document constitutes a waiver of any right guaranteed to you by applicable law.

 

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 to Patient: ___________________

Representative Signature: __________________________________________________   Date Signed: ___________________

Legal Authority (e.g., parent, guardian, POA): ____________________________________________________________

 

 

FOR CLINIC USE ONLY

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