Patient Self-Pay Agreement

Effective September 19, 2026

This agreement is between you and Holistic Medical Services United, LLC. It covers money: what you pay, when you pay it, and what happens if you do not. It should be read with our Billing, Refund & Cancellation Policy, which sets out the detail, and our Terms and Conditions of Use.

1. We do not bill insurance

Holistic Medical Services United, LLC is a self-pay practice. This is not a temporary arrangement or something we make exceptions to.

• We do not accept insurance, Medicare or Medicaid, and we are not in network with any plan.
• We do not submit claims, we do not verify benefits, and we do not obtain prior authorizations.
• You are responsible for the full cost of your care, regardless of whether you hold insurance.
• If you do hold insurance, you are choosing to be seen on a self-pay basis. Your plan may not credit anything you pay us toward a deductible or out-of-pocket maximum.

2. What care costs

These are flat rates for the visit, published in advance and confirmed with you before you are seen:

New patient evaluation

$319

Follow-up appointment

$319

ADHD diagnostic evaluation

$550

Weight loss visit

$149

Therapy session

Call for current rate

Current rates are always shown on our pricing page. We may change them, and a change will not affect an appointment you have already been quoted for.

3. Card on file

• A valid credit or debit card is required on file to book any appointment.
• You authorize us to charge that card for visit fees, late-cancellation fees and no-show fees as described in our Billing, Refund & Cancellation Policy.
• This authorization continues for as long as you are a patient, and until you revoke it in writing. Revoking it does not cancel a charge you have already incurred.
• Keeping a valid, current card on file is your responsibility. If a card expires, is declined or is removed, any fee it was meant to cover remains payable, and we may decline to schedule further appointments until a working card is on file.

4. Your right to a Good Faith Estimate

Because you are a self-pay patient, federal law gives you the right to a written estimate of what your care will cost before you receive it.

• You are entitled to a Good Faith Estimate of expected charges for any scheduled item or service, and you may ask for one at any time before you book.
• Our rates are flat fees, so for a standard visit the estimate and the final charge are the same number.
• An estimate covers the care we provide. It does not cover anything billed by someone else — see Section 5.
• If you are billed substantially more than your Good Faith Estimate, federal law gives you the right to dispute the bill through a patient-provider dispute resolution process. Nothing in this agreement removes that right, and we will not ask you to waive it.
• Ask for an estimate, or raise a question about one, at Hello@holisticmedunited.com.

5. What the fee does not cover

Your visit fee pays for the appointment with your provider. It does not include, and we do not bill for:

• Medication. Your pharmacy charges you directly, at its own prices, and those prices are outside our control.
• Laboratory work and imaging. The lab or imaging centre bills you directly.
• Care from anyone else we refer you to, including any in-person care. That provider sets its own fees.
• Extended appointment time caused by incomplete intake forms or other administrative delay, which may carry an additional fee under our Billing, Refund & Cancellation Policy.

6. Superbills and reimbursement

If you want to try to claim from your insurer yourself, we will give you an itemized receipt (a superbill) on request.

• We do not guarantee that your insurer will reimburse any part of it.
• We are not responsible for the outcome of a claim you submit, and a denied or reduced claim does not change what you owe us.
• We do not submit the claim, correspond with your insurer, or take part in appeals on your behalf.

7. Cancellations and no-shows

Cancelling 24 hours or more before your appointment is free and fully refunded. Cancelling inside 24 hours may be charged in full, and a no-show is charged in full. Repeated late cancellations or no-shows may end the clinical relationship. The full terms are in our Billing, Refund & Cancellation Policy.

8. Unpaid balances

If a balance goes unpaid, we may suspend scheduling until it is settled. In practice this rarely arises: a card is kept on file and visit fees are charged before the appointment, so there is little opportunity for a balance to build up.

If you think a charge is wrong, contact us at Hello@holisticmedunited.com before contacting your bank. A chargeback filed without raising it with us first is dealt with under our Billing, Refund & Cancellation Policy, and most billing questions are resolved faster directly.

9. Your acknowledgement

By signing this agreement at intake, you confirm that you understand:

• This practice does not bill insurance, and you are responsible for the full cost of your care.
• You have seen our rates, and your cost is confirmed before you are seen.
• A valid card will be kept on file and charged as described above.
• You have been told about your right to a Good Faith Estimate.
• Medication, laboratory work and any outside care are billed separately by those providers.
• Paying for a visit pays for an evaluation, not for a particular diagnosis, medication or outcome.

Questions about any of this, before you sign or afterwards: Hello@holisticmedunited.com or 888-391-0272, Monday to Friday, 9:30 AM to 5:30 PM Eastern.