Prescription Policy Agreement

PRESCRIPTION POLICY AGREEMENT

Direct Pay Virtual Clinic

SECTION 1: OVERVIEW AND GOVERNING FRAMEWORK

1.1 Purpose of This Agreement

Direct Pay Virtual Clinic issues prescriptions as part of its telehealth clinical services where medically appropriate and legally permissible. This agreement establishes the policies, legal requirements, and mutual expectations that govern all prescribing activities. It is intended to protect patient safety, ensure compliance with applicable federal and Minnesota law, and establish a clear framework for the provider-patient relationship as it relates to medications.

1.2 Legal Framework

All prescribing activities at Direct Pay Virtual Clinic are governed by the following laws and regulations:

•       Minnesota Nurse Practice Act (Minn. Stat. Ch. 148) — authorizing APRN prescriptive authority

•       Minnesota Board of Nursing rules and collaborative practice requirements (Minn. Rules Ch. 6316)

•       Minnesota Pharmacy Practice Act (Minn. Stat. Ch. 151) — governing dispensing and labeling

•       Minnesota Controlled Substances Act (Minn. Stat. Ch. 152) — governing controlled substance prescribing

•       Federal Controlled Substances Act (21 U.S.C. §§ 801–904) — DEA scheduling and prescribing requirements

•       Ryan Haight Online Pharmacy Consumer Protection Act (21 U.S.C. § 831) — restricting online prescribing of controlled substances

•       Minnesota Electronic Prescribing requirements (Minn. Stat. § 152.126) — mandating electronic transmission of controlled substance prescriptions

•       DEA Telemedicine Prescribing Rules — governing prescribing via telehealth

•       HIPAA Privacy and Security Rules (45 C.F.R. Parts 160–164) — governing privacy of prescription records

1.3 Prescriptive Authority

Prescriptions at Direct Pay Virtual Clinic are issued by Megan Lundberg, APRN-FNP (CNP License #2461751, NPI: 1912770066), an Advanced Practice Registered Nurse with a Family Nurse Practitioner certification, licensed by the Minnesota Board of Nursing. APRNs in Minnesota hold independent prescriptive authority for most medications within their scope of practice under Minn. Stat. § 148.235. All prescribing is conducted within the scope of practice authorized by Minnesota law and consistent with evidence-based clinical standards.

SECTION 2: GENERAL PRESCRIBING POLICY

2.1 Clinical Discretion

The issuance of a prescription is entirely at the clinical discretion of the Provider based on a thorough evaluation of your medical history, current symptoms, relevant clinical findings, and applicable evidence-based clinical guidelines. The completion of a telehealth consultation does not guarantee that a prescription will be issued. The Provider reserves the right to decline to prescribe any medication where, in their professional judgment, prescribing would not be clinically appropriate, safe, or consistent with the standard of care.

2.2 Clinical Evaluation Required

No prescription will be issued without a completed clinical encounter. This means the Provider must have conducted a real-time telehealth consultation with you that includes a clinical history, assessment of your current condition, and clinical reasoning supporting the prescription. The Clinic does not issue prescriptions based solely on patient requests, questionnaire responses, or prior prescriptions from other providers without a current clinical evaluation.

2.3 Diagnosis-Driven Prescribing

All prescriptions are issued in connection with a specific diagnosis or clinical indication documented in your health record. The Provider will document the clinical basis for every prescription. Prescriptions issued for conditions outside the scope of the current consultation may require a separate appointment.

2.4 Off-Label Prescribing

The Provider may occasionally prescribe medications for uses not explicitly approved by the U.S. Food and Drug Administration (FDA) where there is established clinical evidence and professional guidelines supporting such use. Off-label prescribing is legal and common in clinical practice. If an off-label prescription is issued, the Provider will explain the clinical rationale and obtain your informed consent.

SECTION 3: CONTROLLED SUBSTANCES POLICY

3.1 Federal Prohibition on Telehealth Controlled Substance Prescribing

The Ryan Haight Online Pharmacy Consumer Protection Act (21 U.S.C. § 831) and DEA regulations generally prohibit the prescribing of controlled substances via the internet or telehealth without the patient first having been evaluated in person by the prescribing provider. While federal law provides limited exceptions under certain circumstances (e.g., DEA-registered telemedicine clinics, public health emergencies), Direct Pay Virtual Clinic does not qualify for or operate under any such exception and therefore cannot prescribe any controlled substance via telehealth under any circumstance.

3.2 Substances Not Prescribed

The following categories of medications are among those that Direct Pay Virtual Clinic cannot prescribe via telehealth. This list is illustrative and not exhaustive:

 

Schedule	DEA Classification	Common Examples (not exhaustive)
Schedule II	High potential for abuse; no accepted refills	Adderall, Ritalin, Vyvanse (stimulants); OxyContin, Percocet, fentanyl (opioids); Dilaudid, morphine
Schedule III	Moderate-low potential for abuse	Suboxone/buprenorphine (without DEA X waiver), ketamine, anabolic steroids, Tylenol with codeine
Schedule IV	Lower potential for abuse; accepted medical use	Xanax, Valium, Ativan, Klonopin (benzodiazepines); Ambien, Lunesta (sleep aids); tramadol
Schedule V	Lowest potential for abuse among controlled substances	Lyrica (pregabalin), cough preparations with limited codeine, Vimpat

 

3.3 Referral for Controlled Substance Management

If you require a controlled substance for a diagnosed condition, the Clinic will provide a referral to an appropriate in-person provider or specialist who can conduct the required in-person evaluation and manage controlled substance prescribing. The Clinic will cooperate with transfer of relevant medical records to facilitate continuity of care.

3.4 Misrepresentation and Diversion

Any attempt to obtain a controlled substance from Direct Pay Virtual Clinic through misrepresentation, deception, withholding of information, or other fraudulent means is a violation of federal law (21 U.S.C. § 843) and Minnesota law (Minn. Stat. § 152.025) and will be reported to the appropriate law enforcement authorities. The Provider is legally obligated to report suspected drug-seeking behavior or prescription fraud.

SECTION 4: PRESCRIPTION REFILL POLICY

4.1 Refills Require a Clinical Encounter

Prescription refills are not issued automatically or on request alone. Every refill requires a current clinical encounter — meaning a scheduled telehealth consultation with the Provider during which your condition, treatment response, and continued need for the medication are evaluated. This policy applies to all medications, including non-controlled medications for chronic conditions.

This requirement exists to ensure patient safety, monitor for side effects and drug interactions, assess treatment effectiveness, and comply with applicable prescribing standards. Refills issued without appropriate clinical oversight may constitute substandard care and could expose patients to harm.

4.2 Planning Ahead for Refills

You are responsible for monitoring your medication supply and scheduling refill appointments in advance. The Clinic recommends scheduling a refill appointment when you have approximately a seven (7) to fourteen (14) day supply remaining. The Clinic cannot guarantee same-day refill appointments and is not responsible for gaps in medication coverage resulting from a patient's failure to schedule a timely refill visit.

4.3 Emergency Refill Bridge

In limited circumstances, the Provider may at their sole discretion issue a short-term bridge supply of a non-controlled maintenance medication (typically a 7–14 day supply) if you are an established patient with a documented prescription history, you are experiencing an unforeseen gap in coverage, and a full refill appointment cannot be scheduled in time to prevent a lapse in medically necessary treatment. Bridge supplies are not guaranteed and are assessed case-by-case. This provision does not apply to any controlled substance.

4.4 Medication Continuity Responsibility

The Clinic is not responsible for any adverse health outcomes, symptoms, or complications arising from a lapse in medication coverage due to a patient's failure to schedule timely refill appointments, failure to fill a prescription at a pharmacy, pharmacy stock shortages, insurance issues at the pharmacy level, or any other circumstance outside the Clinic's control.

SECTION 5: ELECTRONIC PRESCRIBING

5.1 Electronic Transmission

All prescriptions issued by Direct Pay Virtual Clinic are transmitted electronically to your pharmacy of choice in accordance with Minnesota's electronic prescribing mandate (Minn. Stat. § 152.126). Paper prescriptions are not routinely issued except where electronic prescribing is not technically feasible or where a specific exception applies under state law.

5.2 Pharmacy Selection

You are responsible for designating a pharmacy to receive your prescription at the time of your appointment. Please have your preferred pharmacy's name, address, and phone number available. The Clinic will transmit the prescription to your designated pharmacy promptly following your appointment. Once a prescription has been transmitted, the Clinic cannot guarantee the ability to redirect it to a different pharmacy.

5.3 Prescription Validity and Filling

Prescriptions are valid for the period specified under Minnesota law and the applicable drug category. Non-controlled prescriptions are generally valid for one (1) year from the date of issue. You are responsible for filling your prescription within the valid period. The Clinic is not responsible for prescriptions that expire unfilled due to patient delay.

5.4 Prescription Errors and Corrections

If you believe there is an error in a prescription issued by the Clinic (e.g., incorrect drug, dose, or instructions), contact us immediately at info@directpayvirtualclinic.org before filling the prescription. Do not fill a prescription you believe contains an error. The Clinic will promptly review and correct any verified prescribing errors at no charge.

SECTION 6: PATIENT MEDICATION RESPONSIBILITIES

6.1 Complete and Accurate Medication Disclosure

You are required to disclose all current medications to your Provider at every appointment, including:

•       All prescription medications currently prescribed by any provider

•       Over-the-counter (OTC) medications, including pain relievers, antihistamines, antacids, and sleep aids

•       Vitamins, minerals, and dietary supplements

•       Herbal remedies and natural products

•       Medical marijuana or cannabis products, whether obtained legally or otherwise

•       Any recreational substances, including alcohol

Failure to disclose current medications may result in dangerous drug interactions, incorrect dosing, or contraindicated prescriptions. The Clinic cannot be held liable for adverse outcomes resulting from a patient's failure to disclose current medications.

6.2 Allergy and Adverse Reaction Disclosure

You must disclose all known drug allergies, sensitivities, and prior adverse drug reactions at every appointment. This includes reactions to medications, dyes, contrast materials, and latex. If you experience a new allergic or adverse reaction to a prescribed medication, contact the Clinic immediately and, if the reaction is severe or life-threatening, call 911 or go to the nearest emergency room.

6.3 Adherence to Prescribed Treatment

You are responsible for taking medications as prescribed, including at the prescribed dose, frequency, and duration. Do not stop, reduce, or increase your medication dose without first consulting your Provider. If you experience side effects or concerns about a medication, contact the Clinic before making any changes.

6.4 Pharmacy Responsibility

You are responsible for selecting a pharmacy capable of receiving electronic prescriptions, for filling your prescriptions in a timely manner, and for paying all pharmacy costs. Prescription costs are set by your pharmacy and the medication manufacturer and are not within the control of the Clinic. Discount programs such as GoodRx may be available to reduce costs for certain medications. The Clinic can provide information about discount options upon request.

6.5 Safe Storage and Disposal

You are responsible for storing all medications safely and appropriately, including keeping medications away from children and pets, storing medications at required temperatures, and securing any medications that could be subject to misuse. Unused or expired medications should be disposed of safely. Minnesota residents may use community drug take-back programs or FDA-approved disposal methods (flushing of certain medications where permitted). Information about drug take-back locations is available at www.health.state.mn.us.

6.6 Single-Provider Policy

For safety and continuity of care, you agree to inform Direct Pay Virtual Clinic of all other providers who are prescribing medications to you. If you are receiving the same medication or a medication in the same drug class from multiple providers without each provider's knowledge, this constitutes a safety risk and may constitute illegal activity under Minnesota law. The Clinic reserves the right to decline to prescribe a medication that is already being prescribed by another provider for the same indication.

SECTION 7: POLICIES FOR SPECIFIC MEDICATION CATEGORIES

7.1 Antibiotics

Antibiotics will be prescribed only when there is a clinical indication supported by the patient's symptoms, history, and the Provider's assessment. The Clinic follows evidence-based antibiotic stewardship principles to minimize the risk of antibiotic resistance. Antibiotics will generally not be prescribed for viral infections (e.g., common cold, influenza) unless a secondary bacterial infection is suspected. A full course of antibiotics should always be completed as prescribed, even if symptoms resolve before the course is finished.

7.2 Medications Requiring Laboratory Monitoring

Certain medications require baseline or ongoing laboratory monitoring for safety (e.g., thyroid medications, medications affecting kidney or liver function, certain cardiac medications). If the Provider prescribes a medication requiring laboratory monitoring, they will order the appropriate labs and may require evidence of recent lab results before issuing or continuing a prescription. You are responsible for completing ordered lab work in a timely manner. The Clinic may decline to continue prescribing a medication if required monitoring labs have not been completed.

7.3 Weight Management Medications

Prescription weight management medications (including GLP-1 receptor agonists such as semaglutide and tirzepatide, where prescribed for weight management) will only be issued following a thorough clinical assessment including review of medical history, current weight and BMI, comorbid conditions, and contraindications. Ongoing prescribing of weight management medications requires regular follow-up appointments to monitor response, side effects, and continued clinical appropriateness. These medications may not be available via telehealth in all circumstances.

7.4 Mental Health Medications

The Clinic may prescribe certain non-controlled mental health medications (e.g., SSRIs, SNRIs, certain non-controlled anxiolytics) where clinically appropriate following a thorough assessment. Prescribing of mental health medications via telehealth is subject to applicable clinical guidelines and the Provider's professional judgment. The Clinic does not prescribe benzodiazepines or other controlled substances for mental health indications. Patients with complex psychiatric conditions may be referred to a psychiatrist or licensed mental health professional for comprehensive evaluation and management.

7.5 Hormonal Medications

Hormonal medications, including contraceptives, thyroid medications, and hormone replacement therapy, may be prescribed following an appropriate clinical evaluation. Certain hormonal medications may require baseline laboratory testing before prescribing. Ongoing prescribing of hormonal medications requires regular follow-up to monitor effectiveness and safety.

7.6 Medications Requiring Prior In-Person Evaluation

Certain medications are not appropriate for initial prescribing via telehealth, as they require a physical examination, in-person diagnostic testing, or procedures that cannot be conducted virtually. In such cases, the Provider will advise you to seek an in-person evaluation and may provide a referral. Examples include medications requiring EKG monitoring, ophthalmologic evaluation, or physical measurements that cannot be assessed via video.

SECTION 8: ADVERSE EFFECTS, REACTIONS, AND EMERGENCIES

8.1 Reporting Adverse Effects

You are responsible for contacting the Clinic promptly if you experience any unexpected side effects, allergic reactions, or concerning symptoms after starting or changing a medication. Contact us at info@directpayvirtualclinic.org or through the patient portal. For non-urgent concerns, please allow one (1) to two (2) business days for a response.

8.2 Serious or Life-Threatening Reactions

Signs of a serious drug reaction requiring emergency care include, but are not limited to: difficulty breathing or swallowing; swelling of the face, lips, tongue, or throat; severe rash, hives, or blistering of the skin; rapid or irregular heartbeat; severe dizziness or loss of consciousness; severe abdominal pain; or signs of serotonin syndrome (agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle twitching).

8.3 FDA MedWatch Reporting

Serious adverse drug reactions may be reported to the FDA MedWatch program at www.fda.gov/safety/medwatch or by calling 1-800-FDA-1088. The Clinic will report serious adverse events to the FDA as required by applicable law and clinical standards.

SECTION 9: MEDICATION RECORDS AND PRIVACY

9.1 Prescription Records

All prescriptions issued by Direct Pay Virtual Clinic are documented in your electronic health record and are considered protected health information (PHI) under HIPAA (45 C.F.R. § 164.501) and the Minnesota Health Records Act (Minn. Stat. Ch. 144). Prescription records will be retained in accordance with our record retention policy (minimum seven (7) years under Minnesota law).

9.2 Minnesota Prescription Monitoring Program

Minnesota operates a Prescription Monitoring Program (PMP) under Minn. Stat. § 152.126, which tracks dispensing of controlled substances and certain other monitored prescription drugs. Healthcare providers are required by law to consult the PMP before prescribing monitored substances and to report dispensing of such substances to the PMP. Although Direct Pay Virtual Clinic does not prescribe controlled substances, the Provider may consult the PMP as part of a comprehensive medication history review for patient safety purposes.

9.3 Prescription Records Requests

You have the right to access your prescription records as part of your health records under HIPAA and Minnesota law. Prescription records requests should be submitted in writing to info@directpayvirtualclinic.org. Records will be provided in accordance with our Notice of Privacy Practices and applicable law.

SECTION 10: POLICY VIOLATIONS AND CONSEQUENCES

10.1 Behaviors That May Result in Termination of Prescribing

The following behaviors may result in the Provider declining to issue further prescriptions and/or terminating the patient-provider relationship, subject to applicable laws regarding patient abandonment and continuity of care:

•       Providing false or misleading information about medical history, current medications, or symptoms for the purpose of obtaining a prescription

•       Attempting to obtain controlled substances via telehealth from this Clinic

•       Obtaining the same prescription from multiple providers simultaneously without disclosure ("doctor shopping")

•       Altering, forging, or misrepresenting a prescription issued by the Clinic

•       Sharing, selling, or diverting prescribed medications to others

•       Repeated failure to complete required follow-up appointments or laboratory monitoring

•       Threatening, abusive, or harassing conduct toward the Provider

10.2 Mandatory Reporting

The Provider is legally obligated to report suspected prescription fraud, drug diversion, or controlled substance abuse to the appropriate authorities under Minnesota law and federal law. This includes reporting to the Minnesota Board of Pharmacy, the Drug Enforcement Administration (DEA), and/or local law enforcement as appropriate. Reports will be made without prior notice to the patient where required by law.

10.3 Termination of Prescribing Relationship

If the prescribing relationship is terminated due to a policy violation, the Provider will document the clinical basis for termination and will provide you with sufficient notice and a prescription bridge supply (where clinically safe and legally permissible) to allow for transition to another provider. Termination of the prescribing relationship does not necessarily terminate the overall patient-provider relationship for non-prescription services.

SECTION 11: PATIENT ACKNOWLEDGMENT AND AGREEMENT

By signing below, I acknowledge and agree that:

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

2.     I understand that prescriptions are issued solely at the clinical discretion of the Provider and that completing a telehealth consultation does not guarantee that a prescription will be issued;

3.     I understand and accept that Direct Pay Virtual Clinic does NOT prescribe Schedule II through Schedule V controlled substances via telehealth under any circumstances, and I will not attempt to obtain controlled substances from this Clinic;

4.     I understand that prescription refills require a scheduled clinical encounter and will not be issued based on patient request alone;

5.     I agree to disclose all current medications, supplements, allergies, and adverse reactions to my Provider at every appointment;

6.     I understand my responsibility to take medications as prescribed, to fill prescriptions in a timely manner, and to store and dispose of medications safely;

7.     I understand that I must contact the Clinic or seek emergency care if I experience adverse drug reactions, and that life-threatening reactions require calling 911 immediately;

8.     I understand that prescription records are protected health information and are subject to the Clinic's Privacy Policy and Notice of Privacy Practices;

9.     I understand that providing false information to obtain a prescription is illegal and may be reported to the appropriate authorities;

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

11.   I understand that a copy of this document is available to me upon request at any time.

 

 

Patient Full Name		Date of Birth
Known Drug Allergies		Phone Number
Current Pharmacy Name		Pharmacy Phone
Pharmacy Address		Pharmacy City/State

 

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
Medication History Reviewed		PMP Checked (if applicable)