1. Direct pay / no insurance billing

I understand that Solvion Health and its affiliated medical practices do not accept or bill health insurance of any kind, including:

  • Commercial / employer health plans
  • Marketplace / individual plans
  • Federal or state programs such as Medicare, Medicaid, TRICARE, VA, or similar programs.

I understand that all services I receive through Solvion Health and its affiliated medical practices are provided on a direct pay (cash pay) basis, and:

  • I am personally and fully responsible for payment of all charges.
  • Any fees, membership charges, visit fees, laboratory testing, and other services must be paid directly by me, using my own funds.

I understand that Solvion Health will not submit claims to any insurance plan or government program on my behalf, and:

  • Solvion Health and its affiliated medical practices will not provide CPT (procedure) or ICD-10 (diagnosis) codes for the purpose of insurance reimbursement or claims submission, except where required by law.

2. Federal program beneficiaries

If I am a beneficiary of any federal or state health care program (including but not limited to Medicare, Medicaid, or TRICARE), I understand and agree that:

  • I am choosing to receive services from Solvion Health and its affiliated medical practices outside of those programs on a direct pay basis.
  • Neither I, nor Solvion Health, nor any affiliated medical group, laboratory, pharmacy, or provider will submit a claim for reimbursement to any federal or state health care program for the services and products provided to me through Solvion Health.

I agree that I will not attempt to seek reimbursement from any federal or state health care program for these services.

3. Commercial insurance, HSA, and FSA

If I have commercial or employer health insurance, I understand that:

  • Solvion Health and its affiliated medical practices are out of network and do not contract with any health plans.
  • Services may be considered elective or non-covered by my plan.
  • Solvion Health will not communicate with my insurance company about coverage, prior authorizations, appeals, or claims decisions.

I understand that some patients may choose to use Health Savings Accounts (HSA) or Flexible Spending Accounts (FSA) to pay for services, but:

  • Any such use is between me and my HSA/FSA administrator.
  • Solvion Health does not guarantee that any service, lab, or product is eligible for HSA/FSA reimbursement.

4. Labs, pharmacies, and third-party services

I understand that Solvion Health may coordinate my care with independent laboratories and pharmacies and that:

  • Labs and pharmacies are separate entities, not owned or controlled by Solvion Health.
  • Some charges for lab work or medications may be collected by Solvion Health as a convenience, and others may be billed directly to me by the lab or pharmacy.
  • I am financially responsible for all such charges, including repeat or follow up tests recommended by my provider.

I understand that no additional payment is due at the lab draw site if my panel was purchased through Solvion Health, unless I am specifically informed otherwise in advance.

5. Refunds, cancellations, and missed appointments

I understand that web sales and program enrollments may be non-refundable, and that Solvion Health’s detailed refund and cancellation policy is posted on its website and/or in my onboarding materials.

I understand that:

  • Appointment cancellations with timely rescheduling (for example, at least 24 hours in advance) may be allowed without penalty as described in the policy.
  • Late cancellations or missed appointments may incur a non-refundable fee as specified by Solvion Health.

I acknowledge that it is my responsibility to review Solvion Health’s current Refund and Cancellation Policy, and that by scheduling appointments or purchasing services I am agreeing to those terms.

6. Acknowledgments

By signing this Notice, I acknowledge and agree that:

  • I have chosen to receive services from Solvion Health and its affiliated medical practices on a direct pay basis.
  • I understand that no claims will be submitted to private insurance, Medicare, Medicaid, TRICARE, or any other third party payer for services or products provided through Solvion Health.
  • I am personally responsible for all charges, whether billed by Solvion Health, an affiliated medical practice, a laboratory, or a pharmacy, and I agree to pay such charges in accordance with the payment terms presented to me.
  • I understand that this Notice of Direct Pay and Financial Responsibility is being executed before any services are rendered by Solvion Health or its service providers.
  • I confirm that I am not seeking care for an urgent or emergency medical condition and that I have been advised to call 911 or go to the nearest emergency department if I believe I am experiencing a medical emergency.

Direct Pay Notice