Patient Payment Agreement - Klarity

Overview

This Patient Payment Agreement outlines financial responsibility for patients receiving services from providers on the Klarity Health platform. Patients may choose to pay out-of-pocket (self-pay) or use commercial insurance, employer-sponsored health plans, Medicare, Medicaid, or other state-funded programs. By receiving services through Klarity, you acknowledge your financial responsibility for any applicable costs as outlined below.

Financial Responsibility for Services

Self-Pay Patients

• Patients choosing self-pay are responsible for the full cost of services at the time of booking.

• If a provider is not contracted with an insurance plan or government health program (e.g., Medicare, Medicaid), claims will not be submitted, and payment will be required upfront.

• Upon request, an itemized superbill may be provided for out-of-network reimbursement; however, reimbursement is not guaranteed.

Insured Patients

• If you choose to use insurance, you are responsible for all copays, coinsurance, deductibles, or non-covered services as determined by your insurance provider.

• You must verify your insurance benefits before receiving services. Klarity does not guarantee coverage.

• If your provider accepts insurance but your claim is denied or only partially covered, you will be responsible for the remaining balance.

• Some services may require prior authorization from your insurer. It is your responsibility to ensure authorization before your visit.

Medicare & Medicaid Patients

Medicare Patients

• Some Medicare plans prohibit providers from charging for services already covered under the plan.

• If your provider does not contract with Medicare, you may be required to sign an Advance Beneficiary Notice (ABN) acknowledging your financial responsibility for services.

• If you are a Medicare beneficiary, you should check with your Medicare advocate to determine whether cash-pay services are allowed under your plan.

Medicaid Patients

• Medicaid rules vary by state and may restrict providers from accepting cash-pay patients.

• If your provider does not accept Medicaid, you must agree to pay out-of-pocket and acknowledge that Medicaid will not be billed for services.

• Patients are responsible for confirming whether they may be required to seek services from a Medicaid-approved provider.

Payment Authorization

• By providing payment information, you authorize Klarity to charge your selected payment method (credit/debit card, HSA, FSA) for services received through the Klarity platform.

• Klarity may store your payment details for future transactions until you revoke authorization.

Insurance & Billing Acknowledgment

• Klarity does not submit insurance claims, process reimbursements, or determine coverage eligibility.

• All insurance billing is handled by the provider. Any claim disputes must be addressed directly with the provider or insurer.

• If your insurance coverage status is unclear or pending, payment requirements will be determined by the provider and may require upfront payment.

• If an insurance claim is denied, Klarity will automatically charge the remaining balance to the payment method on file.

Refunds & Cancellations

• Refunds for self-pay patients are available if an appointment is canceled 24+ hours in advance (excluding non-refundable deposits).

• Refunds for insurance-based payments cannot be processed by Klarity and must be requested from the provider.

• If an insurance-related overpayment occurs, patients must work with their provider to request reimbursement.

Acknowledgment & Consent

By using Klarity Health’s platform, you acknowledge and agree to the following:

• You are responsible for verifying your insurance coverage and understanding any financial obligations before receiving care.

• If you are uninsured or elect not to use insurance, you agree to pay for services in full at the time of booking.

• If your insurer denies your claim or does not cover a service, you are responsible for the remaining balance.

• Medicare/Medicaid patients may be required to sign additional consent forms based on program requirements.

• Klarity does not submit claims, determine benefits, or guarantee reimbursement from insurers.

For any questions regarding payment policies, please contact patientsupport@helloklarity.com.