Direct Primary Care (DPC) Membership Agreement Description of 2026

1. Click ‘Get Form’ to open the Direct Primary Care (DPC) Membership Agreement in the editor.
2. Begin by filling out the PATIENT INFORMATION section. Enter your today's date, first name, last name, middle initial, preferred name (if applicable), date of birth, and social security number. Complete your address details including city, state, and zip code along with your home and cell phone numbers.
3. Review the DESCRIPTION OF SERVICES carefully. This section outlines what is included in your membership fee and what services may incur additional charges.
4. In the FEE AGREEMENT section, initial each statement to acknowledge your understanding of the terms regarding payment schedules and responsibilities.
5. Proceed to the INSURANCE DISCLOSURE section. Initial each statement confirming that you understand this agreement does not provide comprehensive health insurance coverage.
6. Complete the CANCELLATION POLICY by initialing each point to confirm your understanding of cancellation terms.
7. Fill out the HIPAA, Privacy and Communications section by initialing each statement regarding your rights to privacy and communication preferences.
8. Finally, complete the DIRECT PRIMARY CARE MEMBERSHIP APPROVAL AND BILLING AGREEMENT by indicating the number of memberships needed and selecting your payment terms. Provide credit card information as required.

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