Financial Responsibility Agreement

This Patient Financial Responsibility and Self-Pay Agreement (this “Agreement”) is between Neko Health PA (the “Neko Clinic,” “we,” “our,” or “us”) and you (“you” or “your”). Please read this Agreement carefully and contact us at hello@nekohealth.com with any questions before you accept. When you check the acceptance box related to this Agreement you agree to the following:

You have voluntarily chosen to receive health care services, items, and supplies from us on a self-pay (cash-pay) basis (we call these the “Services”). You’re asking us not to bill or submit claims for the Services to any health insurance plan or other third-party payor, and you agree that you are 100% personally and fully responsible for paying our charges for the Services, based on our fee schedule, which we can share with you upon request.

The Neko Clinic will not verify your insurance benefits, obtain prior authorization from any payor, or prepare or submit any claim for the Services to a commercial health insurance plan or to any federal or state health care program, including Medicare, Medicare Advantage, Medicaid, TRICARE, or any similar government program (we call these, “Government Health Programs”). For the Services, we don’t participate in any commercial insurance plan of Government Health Program—we’re out-of-network with all of them. Your insurance policy, if you have one, is a contract between you and your insurance company. We’re not a party to that contract, we’re not bound by its terms, and we can’t take responsibility for knowing or applying your benefits.

Payment in full is due at the time we provide the Services, unless we agree in writing to other arrangements. We accept cash, personal check, and major credit and debit cards, including HSA/FSA cards.

Because you’re paying without insurance, the No Surprises Act gives you the right to a written Good Faith Estimate of the expected charges for scheduled Services, which you can request from us at any time. You understand that we’ll provide the estimate within the timeframes the law requires. If you are ultimately billed at least $400 more than the Good Faith Estimate, you may be able to dispute the bill through the federal patient-provider dispute resolution process. To learn more, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Upon checkout, we’ll give you an itemized receipt, which you should keep for your records or, if you have commercial insurance, use to seek reimbursement directly from your insurer at your own election and risk. We can’t promise that any insurance plan will reimburse you for any portion of the Services, that the Services will count toward any deductible or out-of-pocket maximum, or that the Services are covered benefits under any plan. You also agree that you won’t submit, and won’t ask us to submit, any claim for the Services to any Government Health Program, directly or indirectly, and that you will not seek reimbursement for the Services from any Government Health Program.

Please also be aware that HSA/FSA eligibility and other key features of using HSA/FSA funds may change annually and differ between plans. We recommend consulting your plan administrator, HR department, or a qualified tax or financial advisor to understand how these accounts apply to your specific situation.

By accepting this Agreement electronically, you represent either (a) that you are not a beneficiary of Medicare, Medicaid, or any other Government Health Program, or, (b) that, if you are, you have disclosed that fact to us before receiving the Services.

Under HIPAA, if you pay for a Service in full out of pocket, you have the right to request that we not share your protected health information shared in connection with receiving the Services with your health plan for payment or health care operations purposes, and we have to honor that request unless the law requires us to disclose it. If you’d like us to limit what we share with your health plan(s) about the information shared in connection with receiving the Services, just tell our Privacy Office at dpo@nekohealth.com.

You understand that if your payment isn’t completed in full (for example, if a check or card payment is dishonored or reversed), the restriction may not apply to those Services, and we may pursue payment from you.

You’re entering into this Agreement knowingly and voluntarily. You do not have to purchase the Services, and choosing to pay for them yourself isn’t a condition of enrollment in, or eligibility for, any insurance plan or Government Health Program. We’ve given you the chance to ask questions about the Services and their prices and about alternative services and their costs, and you accept full financial responsibility for the Services you’ve chosen.

This Agreement covers the Services identified above and to all Services provided to you from the date of your electronic acceptance until you revoke it. You can revoke this Agreement going forward at any time by giving us written notice. Revocation will not apply to Services we’ve already provided and you remain responsible for all amounts owed for Services provided before you revoked. After you revoke your acceptance of this Agreement, we may decline to schedule or continue non-emergency Services and if you ask, we’ll give you reasonable assistance in transitioning your care.

When you check the acceptance box below, you agree that your electronic acceptance is your electronic signature and creates a legally binding agreement, with the same force and effect as a handwritten signature, under the federal Electronic Signatures in Global and National Commerce Act and the New York Electronic Signatures and Records Act. You agree to receive this Agreement and related notices and disclosures from us electronically, and you confirm that you can access, view, and keep electronic records in PDF format and that you have access to a device and an email or patient portal account to do that. You may (a) request a paper copy of this Agreement at no charge, and (b) withdraw your consent to receive records electronically going forward, just email us at hello@nekohealth.com to do so. Withdrawing consent won’t affect the validity of this Agreement or of anything you accepted before you withdrew.

This Agreement is governed by the laws of the State of New York, without regard to conflict-of-laws principles. This Agreement covers only your financial responsibility for the Services and your insurance-billing elections; it doesn’t change any informed-consent form, notice of privacy practices, or other agreement between you and us. If any part of this Agreement turns out to be invalid or unenforceable, or conflicts with applicable law, the rest stays in effect and applicable law controls. You can download or print a copy when you accept, and we’ll also make a copy available in your patient portal.