Lux Health, LLC d/b/a Goza

Patient Financial Consent Form

Fees, payment, cancellation, and refund terms for Goza services

Effective Date: April 23, 2026

PLEASE READ THIS PATIENT FINANCIAL CONSENT FORM CAREFULLY. IT DESCRIBES THE FEES, PAYMENT OBLIGATIONS, CANCELLATION RULES, AND REFUND POLICIES THAT APPLY TO YOUR USE OF GOZA SERVICES. BY COMPLETING AN INTAKE OR PURCHASING A SERVICE, YOU AGREE TO BE BOUND BY THIS FORM.

1. Overview

Lux Health, LLC, d/b/a Goza ("Company," "we," "us," or "our") operates a direct-to-consumer telehealth practice. We are a cash-pay (self-pay) practice and do not accept insurance or third-party payers for our services. This Patient Financial Consent Form ("Form") explains the fees, payment methods, cancellation policy, refund policy, and other financial terms that apply to your care.

This Form is in addition to, and is incorporated by reference into, our Terms and Conditions and Telehealth Informed Consent. In the event of any conflict between this Form and those documents with respect to fees, refunds, or cancellation, this Form shall control.

2. Fee Schedule

Fees for Goza services are listed below. All fees are in U.S. dollars and are due at the time of service. Fees may change from time to time; the fee in effect at the time you submit your intake is the fee that applies to that visit.

A. Message Visits (Asynchronous)

Standard message visit fee: $79 per visit
The message visit fee covers the provider's review of your intake, clinical decision-making, and (when appropriate) issuance of a prescription or treatment plan.

B. Video Visits (Synchronous)

Standard video visit fee: $99 per visit
The video visit fee covers a live video consultation with your provider plus any associated clinical decision-making and follow-up.

C. Goza Membership

Membership fee: $69 per month, billed as a recurring subscription
Membership includes a defined number of included message visits per year (as described at the point of sale) and discounted rates for additional services.
Member extra message visit fee: $59 per visit (for visits beyond included allotment)
Membership renewal is automatic (see Section 6).

D. Wellness Labs

Wellness lab panels are ordered and fulfilled through our third-party partner, Fullscript, Inc., with specimen collection at Quest Diagnostics Patient Service Centers. Lab fees are billed directly by Fullscript and are separate from, and in addition to, any Goza clinician fee.

Lab panel cost: varies by panel, paid to Fullscript at checkout through the Fullscript platform
Goza lab interpretation/ordering fee (where applicable): disclosed at the time of ordering, paid to Goza
Additional venipuncture, repeat-draw, or after-hours Quest fees (if any) are the sole responsibility of the patient and are charged by Quest Diagnostics directly.

E. Other Fees

Late cancellation fee: $25 (see Section 5)
No-show fee: equal to the full scheduled visit fee
Returned payment / chargeback administrative fee: $25 per occurrence
Records request fee (when permitted by Florida Statute 456.057): actual cost of reproduction, not to exceed statutory caps

3. Accepted Payment Methods

Payment is required at the time of service. We accept the following methods of payment:

Credit and debit cards: Visa, MasterCard, American Express, Discover
ACH bank transfer
Digital wallets and peer-to-peer: PayPal, Venmo, Zelle, Apple Pay, Google Pay (where supported)
Cash (in limited administrative circumstances only)
Wire transfer (for employer / bulk billing only)

Card payments are processed through Stripe, Inc., a PCI-DSS Level 1 certified payment processor. Goza does not see, store, or retain your full card number or CVV. By providing your payment information, you authorize us to charge the payment method you select for the fees set forth in this Form.

4. Insurance Is Not Accepted

Goza is a cash-pay (self-pay) practice and does NOT accept any form of health insurance, Medicare, Medicaid, Tricare, or any other third-party payer. We do not submit claims on your behalf.

Upon your written request, we will provide you with a Superbill or itemized receipt that you may submit to your insurance carrier for possible reimbursement as an out-of-network service. Reimbursement (if any) is a matter between you and your insurance carrier, and Goza makes no representations or guarantees regarding reimbursement.

5. Cancellation, No-Show, and Late Arrival Policy

A. Cancellation of Scheduled Video Visits

If you need to cancel or reschedule a scheduled video visit, you must notify us at least twenty-four (24) hours in advance of the scheduled appointment time by email to support@goza.health or through your patient portal.

Cancellation with at least 24 hours' notice: full refund or credit toward a future visit at your option
Cancellation with less than 24 hours' notice: $25 late cancellation fee (remainder refunded)
No-show (failure to attend without prior notice): full visit fee is forfeited; no refund

B. Late Arrival / Incomplete Forms

You must complete all required intake forms and have your payment method on file at least fifteen (15) minutes prior to your scheduled appointment time. If you fail to do so, Goza may (at our discretion) reschedule or cancel your appointment and treat it as a late cancellation.

C. Message Visits

Because message (asynchronous) visits are delivered by provider review of a completed intake, once a provider has begun their clinical review of your submitted intake, the visit fee is earned and non-refundable (see Section 6). You may withdraw your intake before clinical review has begun by contacting support@goza.health; if withdrawal is confirmed before review has begun, the visit fee will be refunded.

6. Refund Policy

We believe in transparent refunds. This Section describes when a refund will, and will not, be issued.

A. Refunds Will Be Issued

If you cancel a scheduled video visit with at least 24 hours' advance notice (full refund).
If you withdraw your message-visit intake before a clinician has begun clinical review.
If a provider-side technical failure or the provider's inability to render care prevents a visit from being completed, a refund or reschedule will be offered (at our discretion).
If we determine, after initial review, that your condition is not appropriate for telehealth AND no meaningful clinical decision-making or prescription has been issued, a full refund will be issued.
As otherwise required by applicable law.

B. Refunds Will NOT Be Issued

Solely because a prescription was not issued. Clinical decisions are made by the provider's professional judgment; the visit fee covers the provider's time and review, not a specific outcome.
Solely because the prescription, dosage, or treatment recommended was not what you expected or preferred.
After a clinician has begun reviewing a message-visit intake.
For no-shows or late cancellations (as set forth in Section 5).
For patient-side technical failures (inadequate internet connectivity, device malfunction, failure to connect on time).
For lab order fees already paid to Fullscript (refunds, if any, are governed by Fullscript's refund policy).
For any past-month membership fees that have already renewed (see Section 7).

C. How to Request a Refund

To request a refund, email support@goza.health with your name, confirmation ID, date of service, and a brief description of the reason. We will acknowledge your request within three (3) business days and will issue eligible refunds within fourteen (14) business days to the original payment method. If you dispute a charge with your bank or card issuer (chargeback) without first contacting us, a $25 administrative fee may be assessed and recovery rights under this Form are reserved.

7. Subscription and Automatic Renewal Terms

Automatic Renewal Disclosure (California Automatic Renewal Law, Oregon ARL, and similar state laws). By enrolling in the Goza Membership or any other Goza subscription, YOU AUTHORIZE GOZA TO AUTOMATICALLY CHARGE YOUR PAYMENT METHOD AT THE THEN-CURRENT SUBSCRIPTION RATE ON A RECURRING MONTHLY BASIS UNTIL YOU CANCEL. YOUR SUBSCRIPTION WILL CONTINUE UNTIL CANCELLED BY YOU.

Subscription amount: $69 per month (Goza Membership) unless otherwise stated at enrollment
Billing frequency: monthly, on the same day each month as your initial enrollment
Duration: continues until cancelled by you
How to cancel: email support@goza.health with your name and email address, or follow the cancellation instructions in your member portal. Cancellation is effective at the end of the current billing cycle; you will not be charged for the next cycle.
Rate changes: we will provide at least 30 days' advance notice of any material change to the subscription rate
Free or discounted trial (if offered): at the end of any free or discounted trial period, your subscription will automatically convert to the regular recurring rate unless you cancel before the trial ends

We do not provide pro-rated refunds for partial months. Previously-billed subscription fees are non-refundable.

8. Employer-Sponsored Benefits

If you access Goza through an employer-sponsored benefit, your employer (not your health insurance) pays for certain covered visits or benefits. The specific fees, inclusions, and exclusions for employer-sponsored plans are set forth in the applicable employer agreement and benefit description provided to you. Any costs for services beyond what your employer plan covers (for example, extra visits, certain labs, or non-covered conditions) are your responsibility and will be billed to the payment method on file.

9. Failed Payments, Late Payments, and Collections

If a payment fails (for example, due to an expired card, insufficient funds, or a rejected ACH transaction), we will attempt to notify you and may retry the charge. You remain responsible for all fees incurred, regardless of whether the initial charge succeeded. If a balance remains outstanding for more than thirty (30) days after written demand, we may, at our option:

Suspend or terminate your access to Goza services
Refer the outstanding balance to a third-party collection agency (consistent with the Florida Consumer Collection Practices Act and the federal Fair Debt Collection Practices Act)
Recover our reasonable costs of collection, including attorneys' fees, to the extent permitted by applicable law

10. Authorization to Charge

By submitting an intake, enrolling in a subscription, or otherwise purchasing a service from Goza, you authorize Goza (directly or through Stripe, Inc.) to charge the payment method you provide for: (i) the applicable visit, service, or subscription fee; (ii) any applicable late cancellation, no-show, returned-payment, or administrative fee set forth in this Form; and (iii) any fees incurred for additional services you specifically request during the course of your care. This authorization remains in effect until you cancel it in writing.

11. Questions and Contact

If you have any questions about fees, a charge you do not recognize, a refund request, or any aspect of this Patient Financial Consent Form, please contact us before disputing any charge with your bank:

Lux Health, LLC, d/b/a Goza — Billing

Email: support@goza.health
Phone: (305) 306-1387
Website: goza.health

12. Acknowledgment

BY COMPLETING AN INTAKE, SCHEDULING A VISIT, OR ENROLLING IN A SUBSCRIPTION, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO BE BOUND BY THIS PATIENT FINANCIAL CONSENT FORM, AND THAT YOU AUTHORIZE GOZA TO CHARGE YOUR PAYMENT METHOD FOR THE FEES DESCRIBED HEREIN.

Questions? Contact Lux Health, LLC d/b/a Goza at support@goza.health or (305) 306-1387. Website: goza.health