LORIA MOBILE MEDICINE

Provider: Frank Loria, FNP-C

Practice Name: Loria Mobile Medicine PLLC

 

PATIENT CONSENT, PRACTICE POLICIES, AND FINANCIAL AGREEMENT

 

1. Scope of Mobile Services & Approved Locations
 

• North Carolina Jurisdiction Only: You acknowledge and agree that Loria Mobile Medicine and its provider operate strictly within the State of North Carolina. Because clinical licensure and advanced practice authority are legally bound by state lines, services—including both in-person and telehealth visits—are provided exclusively to patients physically located within the borders of North Carolina at the time of service. Any care or virtual communication rendered while a patient is temporarily or permanently out-of-state is strictly prohibited by licensing regulations.
   

• Authorized Private Locations Only: Primary care services are provided exclusively within pre-arranged, completely private indoor environments—such as the patient's private residence or an approved private professional workspace. Care will never be conducted in public places, open outdoor areas (such as parks), vehicles, or unsecured public locations due to the legal requirement to protect patient health information (HIPAA) and maintain clinical standards.
   

• Not an Emergency Service: This mobile practice does not provide emergency medical care. If you or the patient experiences a life-threatening medical emergency (such as severe chest pain, sudden weakness or numbness, difficulty breathing, or severe trauma), you agree to call 911 immediately or proceed to the nearest hospital emergency department.
   

2. Solo Practitioner & Private Examinations
 

• Solo Practice Disclosure: You acknowledge that Loria Mobile Medicine is operated solely by Frank Loria, FNP-C, without additional clinical or chaperone staff present during visits.
   

• Right to a Third-Party Witness: Because visits occur without auxiliary medical staff, certain sensitive physical examinations or private procedures will be performed by the provider alone. You retain the absolute right to have a trusted family member or adult household member of your choosing present in the room during any evaluation or procedure.

3. Patient Rights: Right to Refuse or Stop Care
 

• Right to Withdraw Consent: You or the patient retains the absolute right to decline any examination, diagnostic test, or treatment recommendation at any time.
   

• Right to Halt the Visit: You may stop the physical assessment or terminate the visit at any point simply by telling the provider. You understand that stopping a clinical evaluation mid-visit may limit the provider's ability to establish a complete diagnosis or treatment plan, and you accept responsibility for any health outcomes resulting from an incomplete evaluation.

4. Environment, Household Privacy, & Safety Policy
 

• Private Indoor Space & Bystanders: Clinical encounters require a private room free from interruptions and outside view. While other household members may reside in the home, it is the patient's responsibility to ensure a private indoor space is utilized for the examination. The provider is not liable for inadvertent disclosures of protected health information to bystanders, roommates, or family members if the patient chooses to allow them within earshot or vision during the evaluation.
   

• Physical Safety & Setup: Providing adequate lighting, a stable workspace for medical equipment, and ensuring all pets are safely secured in a separate room for the duration of the visit.
   

• Right to Terminate: The provider reserves the right to terminate a visit immediately and reschedule if the environment is public, unsecured, threatening, hostile, or lacks reasonable privacy.

5. Missed Appointments and Cancellation Policy
 

• Notice Requirement: If you need to cancel or reschedule your mobile appointment, you must notify the practice at least 24 hours in advance. Additionally, if you are not available within ten minutes of the appointment time, then the provider may deem the visit a ‘no-show.’ If either of these situations occur, then a fee of up to $50 may be enforced.

6. Outcome Disclaimer
 

• Limitation of Guarantee: In accordance with North Carolina medical standards, no guarantees, warranties, or assurances have been made regarding the results or outcomes of any examination, procedure, or treatment plan.

7. Electronic Communication Consent
 

• You consent to communication via phone calls, text messaging, and/or email for appointment scheduling, follow-ups, and care coordination. You acknowledge the inherent privacy limitations associated with standard electronic communication channels. Any private patient information that needs to be communicated should be done through the patient portal.

8. Minor Consent, Treatment, and Confidentiality
 

• General Minor Policy & Consent to Treatment: Under North Carolina law, minor patients generally require written or documented consent from a parent, legal guardian, or other person legally authorized to consent to treatment, except where otherwise permitted by law. By signing this agreement on behalf of a minor patient, the signer represents that they have legal authority to consent to the minor's medical care and authorizes Loria Mobile Medicine PLLC to provide medically appropriate evaluation and routine treatment, including medical history and physical examination, point-of-care testing, collection of specimens for laboratory testing, prescription or administration of medications, and other medically appropriate diagnostic or therapeutic care. Certain procedures or treatments may require additional informed consent.
   

• Entry Into the Residence and Adult Presence: Because Loria Mobile Medicine PLLC provides medical services in private residences, permission to enter the residence is separate from consent to medical treatment. For an in-home visit involving an unemancipated minor, a responsible adult age 18 or older who is authorized to permit entry into the residence must be physically present when the provider arrives and must remain at the residence for the duration of the visit. Loria Mobile Medicine PLLC will not enter a private residence based solely on an unemancipated minor's invitation or permission. The adult present does not necessarily need to participate in the medical encounter and, when appropriate, may remain in another area of the residence to protect the minor's privacy. The adult's presence or authority to permit entry into the residence does not, by itself, give that individual legal authority to consent to medical treatment on behalf of the minor.
   

• Adolescent Privacy & Confidentiality: When a minor is legally authorized to consent independently to particular health services, information relating to those services will be handled in accordance with applicable North Carolina and federal privacy laws. The extent of parental access to the minor's medical information may depend on the type of care provided and applicable law.
   

• Sensitive Examinations: Sensitive examinations, including breast and genital examinations, will be performed only when medically appropriate and with appropriate consent. Loria Mobile Medicine PLLC may require an appropriate chaperone to be physically present in the same room and may defer the examination or refer the patient to another healthcare setting if an appropriate chaperone is unavailable.
   

• Emergencies and Other Legal Exceptions: Nothing in this section limits treatment authorized without parental consent under applicable emergency provisions, court orders, emancipation laws, minor self-consent laws, or other applicable state or federal law.

9.    Financial Responsibility and Laboratory Testing Acknowledgement
 

• Payment Method and Card Authorization: A valid payment method is required to complete your booking. You authorize Loria Mobile Medicine PLLC to securely store your card through its payment processor and charge it as described in this agreement.
   

• Payment Before the Visit: For self-pay patients, your card will be charged $50 before the appointment. All prepayments will be applied to your final balance. If your payment cannot be processed, your appointment may be canceled.
   

• Final Charges and Refunds: Any additional charges or remaining valid patient-responsibility balance will be communicated to you and charged to your card after the visit, once your final cost is determined, including after insurance processes your claim when applicable. Any overpayment will be refunded to your original payment method. Charges are subject to applicable law and insurance contractual requirements.
   

• Direct Financial Agreement: You understand and agree that you are directly responsible for all professional fees and cancellation charges incurred, regardless of third-party circumstances.
   

• Elective or Non-Covered Laboratory Services: You understand that diagnostic tests are ordered based on clinical necessity guidelines. If you request a test, screening, or panel that is deemed elective or outside the scope of your insurance plan's medical necessity criteria, you explicitly choose to proceed.
   

• Direct Lab Billing & Financial Liability: You acknowledge that if your insurance carrier denies coverage for any requested test, the testing laboratory (e.g., Labcorp) will bill you directly for the full cost of the analysis.
   

• Practice Indemnification: You agree that your healthcare provider and practice are not responsible for determining your specific insurance policy exclusions or coverage limits. You accept 100% financial responsibility for any laboratory charges. You agree to provide accurate and current insurance information and to promptly notify Loria Mobile Medicine PLLC of changes in coverage. If insurance is billed, you authorize Loria Mobile Medicine PLLC to submit claims to your health insurance plan and to receive payment for covered services. You understand that verification of insurance benefits is not a guarantee of coverage or payment. You are responsible for applicable deductibles, copayments, coinsurance, noncovered services, and other amounts determined to be your responsibility under your health plan, subject to applicable law and contractual requirements.
   

• Outstanding Balances: If you believe a charge is incorrect, you agree to contact Loria Mobile Medicine PLLC promptly so the charge can be reviewed. Unless prohibited by law, nonurgent future appointments may require payment of an outstanding balance or an approved payment arrangement before additional services are scheduled.
   

• Delinquent Accounts: If a valid balance remains unpaid after reasonable billing and collection attempts, Loria Mobile Medicine PLLC may, to the extent permitted by applicable law send additional billing notices or payment reminders; offer or require an appropriate payment arrangement; refer the unpaid balance to a collection agency or other authorized collection service; and pursue available legal remedies to recover amounts lawfully owed. Any collection activity will be conducted in accordance with applicable federal and North Carolina law.

10. Insurance Coverage and Self-Pay Policy
​

• Medicare Beneficiaries: Patients enrolled in Medicare generally cannot elect to use our self-pay pricing for services covered by Medicare. Loria Mobile Medicine bills Medicare for covered services in accordance with Medicare regulations. Patients are responsible for applicable deductibles, coinsurance, and other amounts permitted under Medicare rules. Services not covered by Medicare may be available on a self-pay basis, subject to applicable requirements.
   

• Commercial Insurance Patients: Patients with commercial health insurance are generally expected to use their insurance benefits for covered services when Loria Mobile Medicine participates in their insurance network. Requests to pay out of pocket instead of using insurance will be considered on a case-by-case basis, subject to applicable insurance contracts and regulations.
   

• Patient Financial Responsibility: Patients using insurance are responsible for applicable copays, deductibles, coinsurance, and other amounts permitted by their insurance plan. Insurance eligibility and benefit estimates do not guarantee payment. Final patient responsibility is determined following claim processing, subject to applicable law and contractual requirements.

11. Your Right to a Good Faith Estimate
​

• Federal No Surprises Act: Patients who do not have health insurance or who choose not to use their insurance have the right to receive a Good Faith Estimate explaining the expected cost of their medical care. You have the right to receive a written Good Faith Estimate: at least 1 business day before your appointment if scheduled 3–9 business days in advance and at least 3 business days before your appointment if scheduled 10 or more business days in advance. Upon request, even if you have not scheduled an appointment. Your estimate will include the expected charges for services reasonably anticipated at the time of scheduling. Actual charges may differ if additional services become medically necessary. If you receive a bill that is at least $400 more than your Good Faith Estimate, you may be eligible to dispute the bill through the federal patient-provider dispute resolution process. To request a Good Faith Estimate, please contact Loria Mobile Medicine before your appointment.