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While technology is boundless, regulation is not. The practice of medicine is licensed by individual states. During the video appointment, you must be physically located in a state where your doctor may practice. The form asks the state where you'll be during the appointment; if you're not actually there, a no-show fee will apply.
The form asks new patients to provide valid payment details. The card will be pre-authorized in advance of the appointment and charged afterwards according to the practice's fees schedule. After the appointment, you are welcome to request a superbill to claim out-of-network benefits from your health insurance plan.