A direct provider shall provide a written disclaimer on or accompanying each application for primary care services under a direct agreement with the direct provider and any guidelines distributed by or on behalf of the direct provider that informs a patient of his or her financial rights and responsibilities and that states that the direct provider will not bill a health insurance carrier for services covered under the direct agreement. The disclaimer shall also 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.