Recurring Billing Authorization
By checking the authorization box or submitting payment, you authorize Vynova Health LLC and its payment processor to charge your selected payment method for the program, membership, subscription, or service selected at checkout.
1. Billing Terms
Payment covers only the selected program components expressly disclosed at Stripe checkout. Depending on the program and provider decision, those components may include administrative coordination, the provider consultation arranged through Qualiphy, and, only if prescribed, medication fulfillment and shipping. Stripe checkout displays the amount and any applicable components before payment.
The amount, billing frequency, and renewal date will be shown at checkout before payment is submitted. If you choose a recurring program, recurring charges continue until cancelled according to the Cancellation Policy.
To avoid a renewal charge, cancellation requests must be received at least 48 hours before the next scheduled billing date. Cancellation stops future eligible charges but does not automatically refund past charges or halt work that has already begun.
2. Failed Payments, Refunds, and Limits
If a payment fails, Vynova Health or its payment processor may retry the payment as allowed by law and payment network rules.
If a provider does not approve treatment, medication, pharmacy fulfillment, and shipping amounts, if charged and not yet processed, dispensed, or shipped, may be eligible for refund. Administrative coordination and provider consultation or clinical review fees may be non-refundable once the applicable service has begun.
Once a pharmacy has processed, dispensed, or shipped a prescription, medication-related, pharmacy fulfillment, and shipping charges are not refundable, except where required by law or when an error occurred.
3. Customer Acknowledgment
You agree to keep your payment and contact information current. Payment does not guarantee medical approval, a prescription, medication availability, or a specific outcome. A licensed provider determines whether treatment is clinically appropriate after a synchronous two-way video telehealth consultation.
Acknowledgment: You reviewed the amount and billing frequency, authorize the charge(s), understand recurring billing continues until cancelled, understand cancellation must be submitted at least 48 hours before the next billing date to avoid renewal, reviewed the Refund Policy and Cancellation Policy, and understand approval and prescriptions are not guaranteed.
Name: ___________________________
Date: ___________________________
Electronic Signature / Checkbox: ___________________________
Consent Version: billing_auth_v2_2026_05