Thank you for choosing Jade Medicine PLLC. This agreement explains our financial and insurance policies, membership fees, billing practices, non-covered services, and your responsibilities as a patient. Please read carefully and ask any questions before signing.

Practice Model and Membership Fee

Jade Medicine PLLC operates as a membership-based insurance hybrid practice. Patients may use insurance for covered services and/or pay directly for care.

The monthly membership fee is $55 (or $600/year) and provides:

• enhanced access

• secure messaging allowance

• priority communication

• select administrative support

This fee is a Non-Covered Service. It does not replace health insurance and does not include or cover medical services. It cannot be billed to insurance.

A separate Membership Program Agreement must be signed by all active patients.

Membership begins once your second visit is scheduled, which marks the start of ongoing care. Membership fees are billed automatically once membership becomes active.

Exception: Patients receiving SLIT allergy treatment ONLY are exempt from the membership fee.

Insurance Billing

• We accept certain major insurance plans.

• Covered services will be billed to your insurance.

• You are responsible for copays, deductibles, coinsurance, and any balance not paid by your insurer.

• If insurance denies a claim, you are responsible for payment.

Assignment of Benefits: By signing this agreement, you authorize Jade Medicine PLLC to bill your insurance and receive payment directly.

Out-of-Network or Cash-Pay Patients

• Visit fees are due at the time of service.

• You may request a superbill for possible reimbursement; coverage is determined by your plan.

• All charges for services—including visit fees, the membership fee, and Non-Covered Services—are due directly to Jade Medicine PLLC at the time of service.

Card on File

All patients are required to keep a valid credit or debit card on file.

Your card will be used for:

• Copays

• Deductibles and coinsurance

• Balances remaining after insurance processes a claim

• Non-Covered Services (see below)

• No-show or late-cancel fees

• Visit fees for cash-pay or out-of-network patients

• Monthly or annual membership fee auto-billing (membership fees are automatically charged each billing cycle)

If your card declines, you will be asked to provide an updated card immediately.

Non-Covered Services (NCS)

Insurance does not cover certain tasks or services as determined by your policy. These services are billed directly to you. For questions about what is or is not covered refer to your insurer.

Examples include (but are not limited to):

• Completion of forms, letters, or paperwork outside a visit

• Care coordination with outside providers between visits

• Reviewing outside records or results outside a visit

• Treatment planning or chart review completed outside a visit

• Messaging or portal communication that requires medical decision-making

• Medication refills requiring evaluation outside an appointment

• Telephone encounters that do not meet insurance billing requirements

• Administrative requests or documentation completed between visits

• Medical record requests beyond state-mandated minimums

• Any task or service your insurer determines is non-billable or not medically necessary

• Certain procedures, supplements, or therapies not covered by insurance

• Vitamin and nutrient injections (B12 and others)

• Secure messaging requiring clinical or diagnostic decision-making

• Interpretation of results or follow-up outside a scheduled visit

• Time spent preparing complex treatment plans outside appointments

• Extended visit time (prolonged services/99417) if your insurance does not cover this code(most do)

• The Membership Program Fee ($55/month or $600/year)

These examples are not exhaustive, as insurance plans vary widely. Any service your insurance does not cover will be your financial responsibility. A Non-Covered Services Fee Schedule is available separately.

Work Completed on the Date of Service

Medically necessary work performed during your scheduled appointment or on the date of service—such as letters, paperwork, care coordination, or record review—is included in the total visit time and billed to insurance as part of that visit when appropriate.

Extended Time (Prolonged Services)

If your visit exceeds the standard time due to medical complexity, we may bill prolonged service code 99417. If your insurance does not cover this code, additional time will be billed directly to you at $100 per 15 minutes as a nonn-covered service. Many insurance companies cover this code, but it is your responsibility to check your benefits.

Laboratory Testing

Labs are usually billed by outside laboratories. You are responsible for any charges your plan does not cover.

Many lab tests are covered by insurance and others are not. Many functional and specialty labs do not bill insurance. Payment for these tests is made directly to the laboratory and may or may not be re-imbursible by your insurance.

Some labs may be billed directly by the provider. These charges are due at the time of service and are not covered by insurance.

It is your responsibility to confirm your laboratory benefits with your insurance plan, including coverage, deductibles, coinsurance, and any restrictions related to both standard and specialty testing.

Cancellations and Missed Appointments

Your appointment time is reserved specifically for you. Please cancel or reschedule at least 48 hours before your visit so that the appointment may be offered to another patient.

• Late cancellation (<48 hours): $100

• No-show: $150

These are Non-Covered Services and will be charged to your card on file.

Communication & Secure Messaging

Secure messaging through the Charm patient portal and Spruce is intended for brief questions. Anything requiring evaluation, decision-making, medication changes, review of records, or chart review may require a visit or may be billed as an NCS.

Payment Terms

1. Membership Fees

Membership fees are automatically charged to your card on file on a monthly or annual basis, depending on your selected plan. Membership fees are due immediately each billing cycle.

2. Copays

Copays are due at the time of service and will be charged to your card on file if not collected at the visit.

3. Cash-Pay and Out-of-Network Visits

If you are paying cash or we are out-of-network with your plan, visit fees are due at the time of service and will be charged to your card on file.

4. Non-Covered Services (NCS)

Non-Covered Services are due at the time they are provided and will be charged to your card on file.

5. Patient Responsibility After Insurance Billing

Once a claim is processed by your insurer, any remaining patient responsibility (such as deductible, coinsurance, or any portion the insurer designates as your responsibility, including non-covered items) will be automatically charged to your card on file. A receipt will be provided after the charge is completed.

If your card declines, you will be asked to provide an updated card immediately.

Inclusive and Equitable Care and Equitable Care

We provide inclusive and equitable care to all patients. If you have financial hardship, please speak with us.