Cancellation of Membership with Pinnacle Advanced Primary Care This notification shall acknowledge the mutual agreement to cancel and terminate the Direct Primary Care Membership Program contract with Pinnacle Advanced Primary Care, LLC. The member(s) listed on this term form will be terminated no less than 30-days from the date on this form without further recourse or legal obligation by either party. The original contract is hereby terminated and deemed null and void as of 30-days from the Date of Notification or the date listed under Date Cancellation to be Effective, whichever is the furthest date. The member further understands that if a non-refundable enrollment fee was collected at the time of the original signing of the Membership Agreement, it will not be refunded pursuant to the original signed Membership Agreement under section 2a. The member acknowledges any additional fees outside of the membership fees incurred during this time frame are due and billable. The member acknowledges pursuant to section 2a of the Membership Agreement they must wait 6 months before re-enrolling and pay a $150 re-enrollment fee.
Membership fee: The member understands that Section 14 of the Membership Agreement requires that this form be submitted either in person or electronically no later than 30 days prior to the next credit/debit auto-processing date. The member further understands that they shall be responsible for verifying with the practice that this form was received by the practice 30 days in advance of the next billing date. No refund will be issued once an auto-charge is made. If this form is submitted within the 30-day billing cycle, the member understands that it will result in a final monthly membership fee being auto charged on the established auto draft date. This will entitle the member to a final 30-days of Program Services
By checking the four boxes below you acknowledge the terms of this Term Form. And that you, the member, are cancelling the membership with Pinnacle Advanced Primary Care, LLC,