Patient Financial Responsibility and Acknowledgement

I understand that by signing this Patient Financial Responsibility Agreement, I consent to the terms and conditions set forth below regarding the medical [and/or psychotherapy] services, including psychedelic therapies (the “Therapies”), that I receive from providers using the Journey Clinical, Inc. (“Journey”) platform, including physicians, therapists, and nurse practitioners employed or engaged by Journey Clinical Psychiatry, P.C., Inc., Journey Clinical Psychiatry CA, P.C., and Journey Clinical Psychiatry, TX, PLLC [and affiliated psychotherapists] (“Providers”).

I acknowledge and agree as follows:

• While Journey itself is not a Provider, Journey is responsible for providing the administrative function of billing for all services provided by Journey-affiliated Providers.
• If I have a health insurance policy that I plan to use to receive covered medical services (“Covered Services”) from Providers affiliated with Journey, I have provided Journey with the most updated and correct information about my insurance. If I provide Journey with incorrect or not current information about my insurance, I will be fully responsible for any and all charges for the cost of services, including the Therapies, provided to me through the Journey platform.
• I assume full financial responsibility and agree to pay for all charges for Covered Services that are not paid by insurance, including co-payments, co-insurance and/or deductibles and expenses of every kind and description for all Covered Services provided to me by Providers affiliated with Journey. I know that this includes all payments required under my insurance plan. I agree it is my responsibility to confirm that the Providers affiliated with Journey are participating providers under my health insurance policy.
• I acknowledge that certain components of the Therapies, including, but not limited to, administration of psychedelics, observation and monitoring, may not be covered by insurance (“Non-Covered Services”) and that I am solely financially responsible for any Non-Covered Services.
• Payment for any and all charges related to Covered and Non-Covered Services from Journey or Providers affiliated with Journey will be due either prior to the beginning of my session or immediately thereafter, as instructed by Journey. If I receive any bill from Journey or a Journey-affiliated Provider for amounts due that have been unpaid, I agree to pay any such bill within the stated reasonably expected time.
• Journey accepts most major credit cards and payments via its third-party online payment processing vendor.
• If I have a health insurance policy, I have carefully read the section in my health insurance policy that describes Covered Services. If I have questions about my coverage, I will call the plan administrator to ask questions and clarify my benefits. I am responsible for knowing which services my insurance plan will and will not cover and my financial responsibility (out-of-pocket charges). It is my responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving medical services from Providers affiliated with Journey. If my insurance company requires a referral and I do not have one, then I understand that I will be responsible for all the costs and fees associated with the services I receive (as further discussed below).
• I may incur additional charges at the discretion and reasonable notice of Journey, including without limitation charges for credit card payment processing fees, missed appointments without notice per Journey’s policies, which are subject to change, and any costs associated with the collection of unpaid balances.
• I authorize Journey and Providers affiliated with Journey to release my medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, other third-party payors, and/or other physicians or healthcare entities required to participate in my care.
• I authorize assignment of my insurance benefits to be paid directly to Journey and Providers affiliated with Journey for any services rendered as allowable under standard insurance and other third-party payor contracts. I understand I am financially responsible for charges not covered by this assignment. If I receive payment from my insurance plan for benefits due to Journey or its affiliated Providers for my care, other than as reimbursement for payments I have already made, I agree to promptly sign the payment to Journey, or pay that amount to Journey directly.
• As a courtesy to its patients, Journey is pleased to assist in the submission of insurance claims to certain insurance plans for payment. Currently, Journey-affiliated Providers participate with and bill the health plans identified in our FAQs. Journey also provides the list of insurers and the states we participate in as part of your signup process with Journey.

I understand that I am personally responsible to pay for my care received via the Journey platform for non-covered services, if I do not have insurance, Journey does not participate in my health insurance plan or my insurance does not pay for my care because:

• My health plan requires my primary care physician to give me a written referral before a Journey-affiliated Provider treats me and I did not get a referral;
• My health plan denies payment for these services and leaves me responsible for payment;
• My health plan decides that services I received via the Journey platform are not medically necessary and/or Non-Covered Services;
• My health plan coverage has lapsed or expired at the time I receive services via the Journey platform; or
• I have chosen not to use my health plan coverage.

I understand that the terms herein are contractual and not a mere recital and that I sign this document as my own free act and void of any coercion.

I understand that clicking “I Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Patient Financial Responsibility Agreement.