Patient Self-Pay Agreement
Last revision: April 3, 2023
Telehealth & In person services billing in general
If you choose to use these services, please be aware that the payment policies differ from those of traditional medical providers. We would like to provide you with some information about how the payment policies work, so that you can make an informed decision about using these services.
Providers on the Klarity platform do not accept insurance for telehealth or in-person services. All services are cash-pay only. This means that the patient will be responsible for the full cost of the service, unless otherwise agreed upon.
If the provider is not contracted with a health plan or enrolled in a government health care program (e.g., Medicare, Medicaid) and does not submit any claims for reimbursement (e.g., out of network or otherwise), the provider is not subject to the payment restrictions of that program/plan. There are some minor exceptions, but this is the general rule.
We recommend that you contact your insurance plan to inquire about any billing and claim submission instructions/preferences of the plan. An itemized list of services (superbill) can be issued upon request for out-of-network reimbursement.
By signing this agreement, you acknowledge that you have read and understand the above payment policies and agree to be solely responsible for payment for any telehealth or in-person services received from a provider on the Klarity platform.
Many Medicare health plans include a contractual provision prohibiting providers from charging patients for services already covered under the plan. Generally speaking, if the provider is not contracted with Medicare or enrolled in a government health care program (e.g., Medicare, Medicaid) and does not submit any claims for reimbursement (e.g., out of network or otherwise), the provider is not subject to the payment restrictions of that program/plan. There are some minor exceptions, but this is the general rule.
If the healthcare provider participates in Medicare, and the patient is a Medicare beneficiary, in some cases, services may not be used since billing is cash-pay. We recommend reaching out to your Medicare advocate to confirm that cash-pay services are allowed under your care plan.
Medicaid rules differ by state, and some states limit the ability of providers to charge Medicaid recipients out-of-pocket (even more so than Medicare). The fee for service billing is cash-pay and does not accept Medicaid. You acknowledge that you understand and agree to the following: 1.) You understand that each practice operates on a cash-pay system and does not accept Medicaid as a form of payment. 2.) You agree to pay all fees for services provided by the practice at the time of service. 3.) You understand that each practice does not participate in the Medicaid program, and therefore, Medicaid will not be billed for any services rendered. 4.) You acknowledge that you are responsible for verifying your Medicaid insurance coverage and benefits prior to receiving services from a practice on the Klarity platform.
Agreement for Self-Payment of Services
Providers do not accept any health insurance whatsoever, including Medicare or Medicaid. Services are 100% self-pay by patients. By signing this form, you acknowledge that: 1) You do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) You have health insurance but you do not want to use any insurance benefit for these services, acknowledging that providers do not accept any health insurance.
Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you have selected services for purchase on a self-pay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased. Your licensed clinician has provided you with the charges, in advance, for the services you have requested. By signing below, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.
I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.