Direct Primary Care Membership Agreement

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Direct Primary Care Membership Agreement

This Direct Primary Care (DPC) Membership Agreement specifies the terms and conditions under which you (the “Member”) will participate in the benefits availableunder the West Bend Family Medicine (WBFM) Agreement.

1. This Direct Primary Care Membership Agreement is NOT A HEALTH INSURANCE POLICY and does not cover services or care given at any other facility. This Agreement includes only the specific services as outlined in Section 8 below of this agreement and does not include any major catastrophic medical care provided by emergency rooms, hospitals, urgent care centers,services rendered by specialists or specialty clinics, or offsite laboratories. COVID RAPID TESTS and inhouse phlebotomy draws are also not covered.

2. Member(s) understand that Health Insurance cannot be billed for any services provided by West Bend Family Medicine’s Direct Primary Care participants. Member(s) that may be covered by other health insurance plans with which participating providers are contracted, agree(s) NOT to seek reimbursement from their insurance plan for services received under thisAgreement. West Bend Family Medicine will not file an insurance claim for Member(s), and Member(s) also agree not to file an insurance claim. Member(s) understands that the monthly membership fees required under this contract will not apply towards any health insurance plan deductible. Furthermore, membership under this contract DOES NOT fulfill the personal health insurance mandate under the Affordable Care Act.

3. Please see Section 8 for the list of all covered services under this agreement. All services performed at West Bend Family Medicine and not listed under covered services as outlined in Section 8 must be paid for at time of service. (See Section 9 for more details)

4. The pricing fee schedule for this Direct Primary Care at the date of this agreement is as follows:

INITIATION FEE (waived for existing patients) $50 per person or $80 per family
INDIVIDUALS $99 per month
COUPLES $179 per month ($89 pp)
CHILDREN under 18yrs (with enrolled parent) $25 per month (per child)

5. Initiation fee is due at date of registration and is a one-time, non-refundable charge. If a Member decides to cancel the membership at any time and later rejoins, a new initiation fee shall be charged to reinstate the contract.

6. Member(s) understands that both West Bend Family Medicine and Direct Primary Care Member(s) have the right to terminate this agreement at any time and for any reason. Such termination by either party must be in writing 30 days in advance. Any pre-paid monthly membership fees will be refunded at the prorated amount according to the date of membership termination. Refunds will be issued to Member(s) by stated termination date. Member(s) further understands that dismissal as a patient by the provider assumes an automatic dismissal as a Direct Primary CareMember.

7. The Department of Consumer and Business Services has issued a certification to this practice. You can contact consumer advocates at The Department of Consumer and Business Services at (888) 977-4894,, or

8. Covered Services are as follows:

  • Unlimited office visits, including urgent care, annual wellness exam and family planning
  • Correspondence with your physician via secure text messaging will be responded to within 3 business hours (M-F, 8am-5pm) and within 12 hours otherwise. Emails via our patient portal will be responded to within 48 hours (therefore no urgent messages shall besent via this method). Physicians will not assume responsibility for any urgent medical messages sent via the portal. After hours phone services are available 24/7 and if your physician is out of town or unavailable, a covering partner will take the call.
  • Virtual visits via a secure internet link from the comfort of your home are available at the physician’s discretion during regular business hours in lieu of a clinic visit.
  • Access to same day or next day appointments will be with a covering provider if your physician is unavailable due to personal leave.
  • Extended appointment times of 30-60 minutes
  • Initial Fracture care with casting or splinting if appropriate
  • Wound care, including stitching lacerations
  • Free in-office testing: rapid strep tests, urinalysis, pregnancy tests, diabetes testing and Rapid Influenza screen
  • 2 Free skin biopsies per year and free skin tag removal
  • Cryotherapy as indicated for skin lesions such as precancerous growths or warts
  • Personalized Pediatric care –Vaccines offered at wholesale cost

9. Member(s) understands that there may be additional charges for equipment, laboratory services, pathology, referrals, or any other services that are ordered by our office to be performed by any facility other than West Bend Family Medicine. This Agreement does not cover additional charges for such circumstances. Only the services specifically outlined belowin Section 8 are covered by the membership fees. If a provider renders services beyond the scope of this Agreement, there will be added charges. Member(s) agree to pay for these additional charges at the time of service. If these or any other additional charges are not paidat the time of service, Member(s) agree to allow West Bend Family Medicine to charge the Member(s) account(s) on file for those amounts. Those items available for an additional fee are asfollows:

  • Immunizations and vaccinations (these may be purchased at wholesale cost)
  • Nutritional Screening
  • Pathology fees associated with biopsies such as skin, cultures, pap smears

10. If a Direct Primary Care patient cannot make a scheduled appointment, every attempt must be made to notify the office of the need to cancel. If a patient is a “NO SHOW” to a scheduled appointment without notification, there will be a $25.00 fee added to the patient’s account balance.

11. Monthly membership fees shall be paid by monthly charges to the Member’s credit card, debit card, or automatic bank draft. Charges to the Member’s card will occur every month, either on the 1st or the 15th of the month, depending on the date of the patient’s first appointment. The first month fees shall include the initiation fee and the monthly fee up to 2nd month’s payment. Member shall update credit card, debit card, or banking information when necessary and in a timely manner and will be responsible for any amounts owed to WBFM regardless of whether the account or card is expired, cancelled, or otherwise not accepted for payment. Member(s) agree to pay a $25 added charge each time the Member(s) account declines payment of the monthly charge.

12. This Agreement authorizes West Bend Family Medicine to keep credit card, debit card, or banking information on file, and to charge the Member’s applicable account for monthly fees without requiring West Bend Family Medicine to obtain written authorization for each new charge.

13. Member(s) understands that WITHOUT EXCEPTION, all Members included in this Agreement will not be scheduled for a patient appointment unless the membership fees have been paid up through or beyond the date ofthe desired appointment.

14.West Bend Family Medicine reserves the right to refuse membership to any person for any reason.

15. This Agreement is not complete and binding unless the Member(s) also signs the Automatic Payment or Credit Card Authorization, an Electronic Transmissions Disclosure and Agreement. Those documents are hereby incorporated into this contract by thisreference.

This Agreement is between West Bend Family Medicine LLC and Direct Primary Care Member

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*The Department of Consumer and Business Services issued a certification to this practice. You can contact consumer advocates at the Department of Consumer Affairs at (888)977-4894),, or

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You are filling up 1 out of 3 of the Direct Primary Care registration forms. After completing this form, please fill-up the Authorization for Automatic Payment.