Patient Self-Pay Agreement - Klarity

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 using the Klarity platform, 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.

Medicare

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

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 using the Klarity platform, 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 using the Klarity platform, 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 using the Klarity platform, 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.

Payment Authorization

When you provide your Payment Authorization to Klarity, you authorize Klarity to charge your credit card, debit card, HSA or FSA Card, and/or financial account number (collectively, “Payment Method”) in connection with any and all provider sessions you receive through the Klarity platform. You further authorize Klarity to maintain your Payment Method on file to pay for any and all such sessions until you revoke your authorization.

By accessing the website at helloklarity.com, you are agreeing to be bound by these terms of service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. If you do not agree with any of these terms, you are prohibited from using or accessing this site. The materials contained in this website are protected by applicable copyright and trademark law.

Payment Amounts and Timing

You understand and agree that the amount Klarity charges your Payment Method and the timing of that charge depends on, among other things, the amounts your provider charges and the timing of your sessions. Klarity does not determine the amounts your provider charges for your session. Klarity may also adjust the amount of any charge to reflect any errors, refunds, chargebacks, or other adjustments that may occur.

Updates to and Sufficiency of Your Payment Method

You are responsible for ensuring that your Payment Method is valid, active, and has sufficient funds or credit available to cover the amounts you owe for your provider session. You agree to update your Payment Method promptly if it changes or expires. Klarity is not responsible for any amounts charged that exceed your credit limit or costs you incur because charges result in non-sufficient funds.

Fees and Pricing Structure

To ensure efficient and effective care, patients are encouraged to complete all necessary intake and consent forms prior to their scheduled appointment. Failure to complete required forms before the appointment may result in additional provider fees if extra time is needed during the appointment to review or complete missing forms due to administrative delays.This fee is separate to the total service charge and is non-refundable.

Initial patient visits through the Klarity platform include an initial visit fee and a platform fee, which collectively constitute the total cost of the initial visit. These fees cover the technology, administrative services, tools, and products provided by Klarity to facilitate the patient experience. The remaining portion of the total fees paid by patients is directed to the provider for the clinical services rendered.

The fees are accurate as of the last revision of the Terms and Conditions; however, it may be subject to change. Should any changes occur, we will update all documents to reflect those changes. Patients are advised to review the Self-Pay Agreement and/or the Terms and Conditions regularly to stay informed about current pricing.