Payment Policy — Expression Lactation LLC

Self-pay (out-of-network) clients:

I will provide you with a superbill suitable for you to submit to your insurance. The

superbill (which will also serve as a payment receipt) will be coded appropriately to the

level of service provided during the visit. You agree to pay me at the time of the visit (cash,

check, credit card, or FSA).

Insurance (in-network) clients:

Claims for my care will be submitted directly to Expression Lactation, LLC. Expression

Lactation, LLC will appeal all cost-sharing under the Affordable Care Act which states that

lactation services are preventive and not subject to cost-sharing. If my insurance provider

applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, my

credit card on file will be charged. If that charge is unsuccessful for any reason, I will be

invoiced and I agree to pay within 7 days for all applied charges for all visits.

Expression Lactation, LLC will submit a claim on behalf of myself and my babies. If any

portion of either claim is applied to cost-sharing, I understand that I am required by law to

pay cost-sharing to Expression Lactation LLC. My credit card will be charged upon receipt

of the Estimation of Benefits (EOB) by Expression Lactation, LLC. Every effort will be made

to have my insurance recognize these claims as preventive and not subject to cost-sharing,

and an appeal will be initiated. If successful, I will be refunded any amount that Expression

Lactation, LLC recovers from my insurer.

If one of us (me or my baby) is on different insurance and therefore out-of-network for

Expression Lactation, LLC I agree to pay $150 per visit. I will receive a superbill for this

amount and can submit for out-of-network insurance.

If I have different primary insurance that is out-of-network for Expression Lactation LLC, I

understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded

for any amount either insurance applies to cost-sharing. I will only be refunded if and when

Expression Lactation, LLC receives payment directly from either insurance, and only for the

specific amounts paid by my insurance(s). Expression Lactation, LLC may keep any amount

paid by my insurance(s) over and above the deposit I paid.

Kelsey Schones is providing care to me and to my baby or babies; together we are all the

client of Expression Lactation, LLC

My initial visit includes 2 weeks of follow up support by secure messaging, email, or text.

Continued support is available for a weekly fee of $20. These fees are elective and not

eligible for insurance reimbursement.

If my location has a travel fee applied, I understand that this is not eligible for insurance

reimbursement.

By using this product, you attest that you have purchased a license for this product and are agreeing to the

Usage Terms, Conditions, and Copyright found in the product documentation.

I am responsible to verify my own lactation benefits. Expression Lactation, LLC can only see

that I have benefits, they cannot see if I have any special circumstances that might prevent

my insurance provider from covering services. If my plan denies coverage of lactation

services after the claims have been submitted, I am responsible to pay at the self-pay rate. I

understand I should refer to my plan benefits and call my insurance directly to verify

lactation coverage.

Expression Lactation, LLC may communicate with my insurance company in reference to

the services provided to me and my baby or babies.Expression Lactation, LLC may

communicate with my credit card company or bank for any payment related matters.It is

my responsibility to provide accurate and current payment and insurance information. I

will update my credit card information as needed and am responsible for any costs and fees

associated with my failure to provide updated information.

These policies apply to Expression Lactation, LLC and its representatives.

Payments may be made electronically using a credit card or fund transfer.I use Stripe to

process payments. Square meets the high standards of HIPAA and the banking industry for

security and privacy with regard to financial transactions. However, Stripe may send,

automatically or per your request, email or text message receipts that reveal personal

health information such as the date and type of lactation visit. If you are not comfortable

with this, payment may be made via cash or check instead.

Cancellation policy: I understand that I am responsible for all charges associated with this

visit. If I cancel with less than 24 hours’ notice, my credit card on file will be charged $25.