CONCEPT #34 OF 100 · Medical, Dental & Clinical Practices · LAYOUT: asymmetric_sidebar
Direct Primary Care (DPC) & Longevity Clinic Membership Agreement
Standard / Reference: State Direct Primary Care Medical Home Act · IRC § 223(c)(1)(B) HSA Eligibility Disclosure
Why professionals use this template: DPC and longevity clinics requiring state-mandated disclosures that the monthly membership is not health insurance, paired with transparent wholesale lab/DEXA pricing.
144-DPI VECTOR PREVIEW · PAGE 1 OF 1
ACROFORM READY
Included Financial Metrics & Line-Item Schedule
Target Roles: Direct Primary Care (DPC) Physicians, Longevity Clinics & Functional Medicine · Search Keywords: direct primary care dpc patient membership agreement template pdf, concierge medicine retainer contract, dpc non-insurance statutory disclosure, wholesale lab and imaging pricing schedule
MONTHLY DPC MEMBERSHIP
$150.00 / MONTH
OFFICE & TELEHEALTH COPAY
$0.00 UNLIMITED
PANEL CAPACITY CAP
Max 400 Patients / MD
WHOLESALE LAB SAVINGS
85%–92% Below Retail
| CODE | DESCRIPTION & TECHNICAL SPECIFICATION | BASIS / QTY | AMOUNT / DELTA |
|---|---|---|---|
| DPC-MEM | Monthly Direct Primary Care Membership: Same/Next-Day 60-Min Visits, Direct Physician Text/Call | $0 Visit Copay | $150.00/MO |
| LAB-PNL | Included Annual Executive Biomarker Panel (CBC, CMP, ApoB, Lp(a), HbA1c, hs-CRP, Thyroid, Vit D) | 1x Annual Included | $0.00 |
| DEXA-01 | Dual-Energy X-Ray Absorptiometry (DEXA) Body Composition + Visceral Fat + VO2 Max Baseline | Member Wholesale | $95.00 |
| DIS-INS | Statutory Notice: This Agreement is a Direct Retainer and is NOT Health Insurance Coverage | State DPC Statute | DISCLOSED |
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