This Direct Primary Care Membership Agreement (the "Agreement") is entered into by and between Sisu Health DPC LLC ("Practice") and the undersigned patient ("Patient"). By signing this Agreement, the Patient agrees to the following terms and conditions related to their membership at Sisu Health.
Sisu Health Direct Primary Care Patient Agreement
We regard the patient-provider relationship with the utmost reverence, and we thank you for entrusting us with your health care.
Communication is at the center of our care, and this Agreement explains how we will work together. This Agreement is made between Practice, and You (“You” or “Patient”). Practice offers primary care services in exchange for certain fees paid by You as described in this Agreement on the terms and conditions described below.
AGREEMENT
1. Services. As used in this Agreement, the term Services means primary care services and certain amenities (collectively “Services”), which are offered by Practice.
a. Volume of Services. The number of in-person and virtual visits you may receive is not limited by this Agreement.
b. Availability. Practice will make every effort to address Your medical needs in a timely manner, but we cannot guarantee availability, and we cannot guarantee that You will not need to seek treatment in an urgent care or emergency department setting.
c. Included Services. Your membership includes primary care, including well and sick care, and basic gynecological services. Your provider will make an appropriate determination about the scope of primary care services offered by Practice on a case-by-case basis. Some services available in our office, such as rapid strep tests or urinalysis, are available at no additional cost to you. Some services, such as add on services, are available in our office and incur an additional fee plus applicable Washington State sales tax (“Itemized Charges”).
d. Excluded Services. You may need the care of hospitalists, specialists, emergency rooms, urgent care centers, laboratory testing, radiologic testing, pathology studies, surgery and specialist consultations, and dispensed medications that are outside the scope of this Agreement. We highly recommend that you maintain health insurance, which may or may not cover the costs of these services. Practice will endeavor to place orders for Excluded Services in a manner that is cost effective that may be billed through the third-party.
e. Refill Policy. Medication prescriptions should be requested during your appointment to allow for discussion on effectiveness and duration. Occasionally, refills may be needed between appointments. Please allow up to three (3) business days for refills requested outside of scheduled appointments. Practice will not authorize prescriptions if a patient does not have a future appointment scheduled, as state and federal regulations require active treatment monitoring for prescribed medications. Practice reserves the right to decline prescriptions for medications prescribed by other providers or for conditions outside the scope of care, including narcotic pain medications. Prescriptions are not guaranteed on the first visit or in cases of suspected misuse of prescription or over-the-counter substances.
f. Emergency Care. In an emergency or any situation that could reasonably be perceived as an emergency, Patients should proceed to the nearest emergency department or call 911. Practice does not provide emergency or urgent care services.
g. Alternative Provider. If a Patient's primary provider is on vacation or otherwise unavailable, an on-call provider will be accessible for telecommunication-based guidance. If in-person care is needed, Practice will coordinate coverage with a qualified provider.
2. Consent to Treat. You acknowledge and hereby authorize Practice to use and/or disclose Your health information which specifically identifies You, or which can reasonably be used to identify You, to carry out Your treatment, payment, and healthcare operations. Treatment includes the administration of procedures, medications, anesthetics, diagnostic tests, and other medical interventions deemed necessary by Your provider or their designee.
3. Scheduling. In order to best serve the needs of all our patients, we prefer that you schedule Your visit more than 24 hours in advance when possible.
a. Missed Appointments. We kindly request that you provide us with a minimum of 24 hours’ notice if you are unable to attend a scheduled appointment. Your advance notice helps us provide the best possible experience for all of our patients.
4. Fees. In exchange for Services, You agree to pay Practice:
a. Monthly Fee. The Monthly Fee for primary care services. Practice reserves the right to adjust its fees with thirty (30) days’ notice to You to maintain financial viability.
b. Itemized Charges. Any additional Itemized Charges for services not included in the membership.
c. Monthly Fee. Your Monthly Fee, as outlined in the membership chart, covers primary care services for the corresponding month. Payment is due no later than the fifth (5th) day of each month and will be automatically billed to the payment method on file. If You sign up in the middle of the month, the first month's fee will be prorated based on the remaining days in that month. The following payment methods are accepted: cash, checks payable to Sisu Health, and debit or credit cards (including HSA/FSA accounts). If a payment is declined, the Patient's appointment will be rescheduled upon successful payment.
d. Enrollment Fee. A one-time $100 enrollment fee applies to all new memberships. If You enroll mid-month, Your first month's fee will be prorated based on the remaining days in that month.
Sisu Membership Costs
$ 150 Individual
$ 250 Couple
$ 35 Children (Ages 13-21)
$ 125 Individual Parent with Child(ren)
*Very Large families, greater than four, will be discussed case-by-case
5. Disclaimer of Non-Insurance. Fees paid are not health insurance. You acknowledge and understand that this Agreement is not a health insurance plan, and not a substitute for health insurance or other health plan coverage, such as participation in a Health Management Organization (“HMO”). This Agreement is solely for primary care services provided directly to You by our practice. We are required to notify you that some of the benefits you will receive under this Agreement (such as an annual wellness exam) might be included in some health insurance plans without an additional fee to you. This Agreement does not cover hospital, specialist, or any services not directly provided by this practice. It is highly recommended that You maintain health insurance for care you may need that is not part of our Services.
6. Non-Participation in Health Insurance. You acknowledge that neither Practice, nor the Provider(s) participate in any private health insurance or HMO plans, including Medicaid program. Neither Practice nor its Provider(s) make any representations regarding third party insurance reimbursement of fees paid under this Agreement, and such reimbursement is not anticipated by this Agreement.
7. Non-Participation in Medicaid. You acknowledge that, pursuant to state law, Practice and its Provider(s) do not participate in Washington’s Medicaid program. Under state law, non-participating healthcare providers cannot provide medical services to Medicaid recipients. As a result, Medicaid cannot be billed for any Services provided under this Agreement. Additionally, You agree not to submit claims to Medicaid or seek reimbursement for any such services.
8. Non-Participation in Medicare. You acknowledge that, pursuant to federal regulations, Practice and its Provider(s) have elected “opt-out” status from Medicare participation. This means that Medicare cannot be billed for any Services provided under this Agreement. Additionally, You agree not to submit claims to Medicare or seek reimbursement for any such services.
9. Termination.
a. While we value Your membership, You are under no obligation to continue receiving Services. You may terminate this Agreement at any time by providing thirty (30) days’ written notice to Practice.
b. Upon termination of Your membership, You will no longer be eligible for medical services through Practice, including medication refills.
c. If Your decision to terminate is based on a grievance with Practice, You agree to allow us an opportunity to address and resolve the issue before submitting written termination notice.
d. If Practice elects to terminate this Agreement, it will provide written notice and may assist in the transition of Your care where appropriate. Practice reserves the right to accept or decline patients based on our ability to appropriately manage their primary care needs, just as You have the right to choose Your healthcare provider.
e. Certain circumstances may warrant immediate termination of this Agreement by Practice, including, but not limited to: Failure to pay membership fees or any applicable charges when due. Engaging in fraudulent activity related to Your membership or use of Services. Failure to adhere to the recommended treatment plan. Disruptive, abusive, or threatening behavior that endangers staff, providers, or other patients. Misuse, diversion, or abuse of prescription medications, including opioids or other controlled substances. Violation of Practice policies regarding medication management, including controlled substances. Practice reserves the right to discontinue prescriptions of controlled substances, including opioids and benzodiazepines, at any time if there is suspicion of misuse, abuse, or non-compliance with medical recommendations. Practice ceasing operations.
10. Re-Enrollment. If You choose to discontinue Your membership and You later wish to re-enroll, Practice reserves the right to decline re-enrollment or require You to pay a re-enrollment fee that is equivalent to three (3) times the then existing Monthly Fee applicable to your membership, excluding discounts.
11. Privacy & Communications.
a. Limited Disclosure. Practice will not disclose your Protected Health Information (“PHI”) for reasons unrelated to the delivery of Services, or the provision of other health care services on Your behalf.
b. Your Privacy Rights. Practice will adhere to its obligations regarding your privacy rights as identified in Practice’s Patient Notice of Privacy Practices.
c. Methods of Communication. You acknowledge that Practice communications may include e-mail, facsimile, video chat, instant messaging, and cell phone, and such communications by their nature cannot be guaranteed to be secure or confidential. If You initiate a conversation in which You disclose PHI on any of these communication platforms, then You authorize Practice to communicate with You regarding all PHI in the same format. Practice will not use Your PHI for marketing communications without Your explicit written consent. Patients may opt out of any communications at any time.
12. Telemedicine. Not all medical conditions may be appropriate for telemedicine. The Patient understands that some conditions may require an in-person visit, and telemedicine may not be suitable. The Patient may withdraw consent for telemedicine at any time without affecting their right to receive future care or treatment. If consent is withdrawn, all other terms of the Agreement will remain in effect.
13. Use of Scribe. Sisu Health utilizes an AI-powered scribe for medical documentation. This tool transcribes provider-patient interactions solely to enhance accuracy and efficiency in charting. Patient consent is obtained as part of the general treatment consent process. All transcriptions are securely processed and stored per HIPAA regulations. Patients may opt out of AI scribe usage at any time without impact on their care.
14. Additional "Add On" Services. Some services offered at Sisu Health, such as Botox, skin care treatments, etc., are considered add-on services. The pricing for these services is available upon request and billed separately.
15. Miscellaneous.
a. Amendment. No amendment or modification of this Agreement shall be valid unless in writing and signed by both Parties.
b. Anti-Referral Laws. Nothing in this Agreement, nor any related oral or written agreement, requires or is intended to induce or influence patient admissions, referrals, or the generation of business between Practice and any other entity. This Agreement does not interfere with a Provider’s independent medical judgment in determining appropriate patient care.
c. Assignment. This Agreement, and any rights You have under it, may not be assigned or transferred by You.
d. Authorization for Agreement. The execution and performance of this Agreement have been duly authorized by all necessary laws, resolutions, and corporate or partnership actions, making this Agreement valid and enforceable in accordance with its terms.
e. Captions and Headings. Section headings are included for reference only and do not modify, restrict, or expand any provisions of this Agreement.
f. Entire Agreement. This Agreement constitutes the entire agreement between the Parties regarding its subject matter and supersedes all prior agreements, understandings, negotiations, or representations, whether oral or written.
g. Governing Law & Arbitration. This Agreement is governed by the laws of Washington State, without regard to conflicts of law principles. All disputes arising under this Agreement shall be settled through binding arbitration. The arbitration provider shall be selected solely at Practice’s discretion, and arbitration costs shall be equally shared by the Parties.
h. No Waiver. A waiver of any breach of this Agreement shall not be interpreted as a waiver of any other provision, whether of a similar or different nature. Delay in responding to a breach shall not be construed as a waiver of that breach.
i. Non-Discrimination. Practice will not discriminate against You or terminate this Agreement based on sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, sexual orientation, citizenship, primary language, immigration status, or any other protected classification. However, Practice reserves the right to accept or decline patients based on its ability to appropriately manage their primary care needs.
j. Notices. Any required or permitted notices or payments under this Agreement shall be deemed delivered when provided in writing, whether by electronic transmission, hand delivery, or proof of deposit in the U.S. mail. Delivery shall be considered complete on the date of actual receipt, as evidenced by a return receipt, courier record, or verified digital timestamp.
k. Severability. If any provision of this Agreement is found to be invalid or unenforceable by a court of competent jurisdiction, the remainder of the Agreement shall remain in full force and effect. The invalid provision shall be modified or interpreted to the minimum extent necessary to comply with applicable law while preserving its original intent. If this Agreement is determined to be unenforceable in its entirety and Practice is required to issue a refund, You agree to pay an amount equal to the fair market value of Services actually provided during the period covered by the refunded fees, based on prevailing rates in the Practice area.
l. Survival. Any provisions of this Agreement that create obligations extending beyond its termination shall remain in effect, regardless of the reason for termination.
IN WITNESS WHEREOF, the Parties hereto or their duly authorized representatives have executed this Agreement as of the Effective Date first written below.
PATIENT ACKNOWLEDGEMENTS
Please read each statement carefully and initial to indicate your agreement.
- I acknowledge that Practice has advised me to maintain health insurance for coverage of all Services not specifically provided under this Agreement. I further acknowledge that this Agreement is not a health insurance plan and does not replace health insurance coverage.
- I acknowledge that I do not expect Practice to file or submit any third-party insurance claims on my behalf, including Medicare.
- I acknowledge that Practice and its Provider(s) have elected “opt-out” status from Medicare participation, meaning Medicare cannot be billed for any services provided under this Agreement.
- I acknowledge that I am not currently experiencing a medical emergency. In the event of an emergency, I agree to call 911 immediately or seek care at the nearest emergency facility.
NOTICE OF PATIENT PRIVACY PRACTICES
This Notice describes how your medical information may be used and disclosed and how you can access your health information. Please review it carefully.
Practice is required by law to provide this Notice so that you understand how we may use or share your health information, referred to as Protected Health Information (PHI).
We are legally obligated to adhere to the terms outlined in this Notice. If you have any questions, please contact us.
Understanding Your Health Record and Information
Each time you receive care at Practice, a record is created containing your health and financial information. Typically, this record includes information about your condition and treatments provided.
We may use and disclose this information to:
• Plan your care and treatment.
• Communicate with other health professionals involved in your care.
• Document the care you receive.
• Educate healthcare professionals.
• Provide information to public health officials.
• Evaluate and improve the quality of care we provide.
Understanding how your health information is used helps you:
• Ensure its accuracy.
• Better understand who may access your health information.
• Make informed decisions about disclosing your information.
How We May Use and Disclose Your PHI
The following sections describe when and how we may use or disclose your health information. While not all possible uses are listed, all permitted disclosures fall under one of these categories:
For Treatment. We may use or disclose your PHI to provide and coordinate your medical care. This includes sharing information with doctors, nurses, therapists, pharmacists, and other healthcare providers involved in your treatment. Example: If you are receiving treatment for a wound, a provider may need to know if you have diabetes, as this may impact healing.
For Health Care Operations. We may use and disclose your PHI for healthcare operations, which include, internal management and administrative activities, improving the quality and effectiveness of our care, training staff and healthcare professionals, ensuring compliance with regulations, and conducting audits and quality assessments. In some cases, we may share information with other healthcare entities involved in healthcare operations, provided they follow appropriate privacy practices.
Other Permitted Uses and Disclosures of Your Health Information
• Affiliate Providers. Some services are provided by our affiliate providers, and we may disclose information to them for continuity of care.
• As Required by Law. We will disclose health information when legally required by federal, state, or local laws.
• Business Associates. We may share PHI with contractors who perform services on our behalf (e.g., electronic health record providers) while ensuring they maintain privacy standards.
• Coroners, Medical Examiners, and Funeral Directors. We may disclose information for identification purposes or to determine the cause of death.
• Individuals Involved in Your Care. Unless you object, we may share PHI with family members, caregivers, or others involved in your treatment or payment of care.
• Law Enforcement. PHI may be disclosed when requested by law enforcement agencies for legally permitted reasons.
• Marketing Activities. We may use de-identified information for internal marketing about our services but will not share PHI for external marketing without your explicit written consent.
• Military and Veterans. If you are in the Armed Forces, we may disclose PHI as required by military command authorities.
• National Security and Intelligence Activities. PHI may be disclosed for authorized national security purposes.
• Organ and Tissue Donation. If you are an organ donor, we may share PHI with organ procurement organizations.
• Reminders and Health-Related Benefits. We may contact you for appointment reminders or provide information about health-related services.
• Health Oversight Activities. PHI may be disclosed for regulatory oversight, inspections, audits, and compliance activities.
• Judicial and Administrative Proceedings. We may disclose PHI in response to court orders, subpoenas, or other legal proceedings.
Other Uses of Health Information
Any uses and disclosures not covered by this Notice will require your written authorization. You may revoke your authorization in writing at any time. We cannot take back any disclosures already made with your consent.
Your Rights Regarding Your Health Information
Although your health record belongs to Practice, the information contained in it belongs to you.
You have the following rights:
• Accounting of Disclosures. You may request a list of certain disclosures we have made, except those made for treatment, healthcare operations, or legally required reasons.
• Amendments. If you believe your record is inaccurate or incomplete, you may request an amendment.
• Copies of Your Health Records. You have the right to review and obtain a copy of your PHI, with limited exceptions.
• Copy of This Notice. You may request a paper copy of this Notice at any time, even if you received it electronically.
• Right to Request Alternate Communications. You may request that we communicate with you in a specific way (e.g., by email or phone).
• Request Restrictions. You may request restrictions on how we use or disclose your PHI, such as limiting disclosure to family members.
Changes to This Notice
We reserve the right to update this Notice at any time. Revised Notices will be available in our office and on our website.
Complaints
If you believe your privacy rights have been violated, please contact us immediately. You will not be penalized for filing a complaint. You may also file a complaint with the U.S. Department of Health and Human Services (HHS).
