Nebraska Revised Statutes Chapter 71. Public Health and Welfare § 71-9504. Direct agreement; requirements; notice; copy to direct patient

(a) A direct agreement shall be in writing;

(b) A direct agreement shall be signed by the direct provider or an agent of the direct provider and the direct patient or the direct patient's representative;

(c) A direct agreement shall describe the scope of the primary care services included in the direct agreement;

(d) A direct agreement shall state each location where primary care services may be provided and whether out-of-office services are included;

(e) A direct agreement shall specify the direct service charge and any other charges for primary care services not covered by the direct service charge;

(f) A direct agreement shall specify the duration of the direct agreement, whether renewal is automatic, and procedures for renewal if required;

(g) A direct agreement shall specify the terms of the direct agreement and the conditions upon which the direct agreement may be terminated by the direct provider, including at least thirty days' notice to the direct patient in accordance with section 71-2085;

(h) A direct agreement shall state that the direct agreement is terminable at will by written notice from the direct patient to the direct provider;

(i) A direct agreement shall state that if a party provides written notice of termination of the direct agreement, the direct provider is required to refund to the direct patient all unearned direct service charges within thirty days after the date of the notice of termination;

(j) A direct agreement shall prominently state in writing that the direct patient is required to pay the direct provider for any service not specified in the direct agreement and not otherwise covered by insurance; and

(k) A direct agreement shall include a notice that reads substantially as follows:

NOTICE: This direct primary care agreement does not constitute insurance and is not a medical plan that provides health insurance coverage for purposes of any federal mandates. This direct primary care agreement only provides for the primary care services described in the agreement. It is recommended that insurance be obtained to cover medical services not provided for under this direct primary care agreement. You are always personally responsible for the payment of any additional medical expenses you may incur.