CROSSOVER HEALTH DIRECT PRIMARY CARE Membership Agreement
Welcome to our Crossover Health Direct Primary Care practice (the “DPC Practice”). As a patient of
our DPC Practice (“Patient” or “you”), you agree to these Terms of Service (the “Terms”). These Terms
shall be effective as of the date of your signature below (the “Effective Date”).
1. DPC PRACTICE SERVICES
A. DPC Practice Services Covered under Monthly Fee Arrangement. As a patient of our DPC
Practice, you will receive certain basic medical services described on Exhibit A (the “DPC
Practice Services”), under the monthly DPC Practice Fee described below. Please note that the
monthly DPC Practice Fee will only apply to the DPC Practice Services specifically described on
Exhibit A, although we may provide or arrange for additional services under separate
arrangements. DPC Practice also may add or discontinue DPC Practice Services at any time, at
the sole discretion of DPC Practice. DPC Practice shall provide you with at least sixty (60) days’
advance written notice upon any change to the DPC Practice Services set forth on Exhibit A.
B. Non-Covered Services. You understand and acknowledge that you are responsible for any
charges incurred for health care services (i) performed outside of the physical office space
location set forth above, including without limitation, emergency room visits, hospital and
specialist care and imaging and lab tests performed by third parties; (ii) provided by the DPC
Practice, but not specifically described on Exhibit A and/or DPC Practice Services in excess of
those which have been selected and paid for by you as provided in Exhibit A (collectively, “NonCovered
Services”). DPC PRACTICE STRONGLY ENCOURAGES YOU TO MAINTAIN
HEALTH INSURANCE WHILE YOU ARE A PATIENT OF THE DPC PRACTICE TO
COVER SUCH NON-COVERED SERVICES.
2. LOCATIONS. You may receive services at the following locations during regular business hours:
A. Available locations and business hours can be found at crossoverhealth.com/locations-bay-area.
B. In order to ensure the service that you are looking for is available at your desired time and
location, please schedule your appointments by calling or using the online patient portal.
3. BILLING AND PAYMENT
DPC Practice Fee. You agree and acknowledge that you will be responsible for a yearly access fee at
time of registration and at the time of each future renewal. In addition to the Access fee, there will be a
monthly fee (“DPC Practice Fee”) in accordance with the schedule attached hereto as Exhibit B (“DPC
Practice Fee Schedule”). The DPC Practice Fee shall cover all costs and expenses owed by you for
access to and receipt of DPC Practice Services as set forth on Exhibit A but will not cover Non-Covered
Services.
A. Payment Schedule. DPC Practice Fees will be due on the first day of each month following the
Effective Date, for the services to be provided in the following month. The Practice Fees will be
automatically drawn from your credit card on file. (e.g. if you sign-up on November 15th, your
DPC Practice Services will become effective on December 1, and the DPC Practice Fee for the
month of December will be collected on December 1). DPC Practice Fees will not be pro-rated
for any month. Any fees or charges that are not included in the DPC Practice Fee (i.e. fees for
Non-Covered Services) will be due at the time of service.
B. Late Fee. If the DPC Practice Fee is late, you may be subject to a late charge of 20% of your
monthly fee and DPC Practice may, in its sole discretion, terminate your participation as a patient
in the DPC Practice.
4. TERM AND TERMINATION
A. Term. Your participation as a patient in the DPC Practice is for one year and pursuant to these
Terms. The term shall automatically renew each year, beginning on the first day of the month
after the anniversary of the Effective Date.
B. Termination by DPC Practice. DPC Practice may terminate your participation as a patient in the
DPC Practice upon providing you advance written notice. Such termination shall be effective on
the last day of then-current calendar month. Upon termination, DPC Practice shall cooperate in
the transfer of your medical records to your new primary care physician, upon your written
request and direction.
C. Termination by You. You may terminate your participation in the DPC Practice at any time and
for any reason, upon providing advance written notice to DPC Practice. Such termination shall be
effective on the last day of the then-current calendar month. Your access fee shall be refunded if
you have not utilized any DPC Practice Services and shall be nonrefundable, if you have utilized
any DPC Practice Services. DPC Practice Fees shall not be pro-rated for any month. Monthly
DPC Practice Fees will continue to accrue until your written notice of termination is received by
DPC Practice at our office location set forth above.
5. INSURANCE DISCLAIMER
YOU UNDERSTAND AND ACKNOWLEDGE THAT DPC PRACTICE AND THE DPC
PRACTICE SERVICES PROVIDED TO YOU AS A PATIENT OF THE DPC PRACTICE
PURSUANT TO THESE TERMS DOES NOT CONSTITUTE A CONTRACT OF INSURANCE,
NOR DOES THE DPC PRACTICE PROVIDE COMPREHENSIVE HEALTH INSURANCE
COVERAGE.
You understand and acknowledge that the DPC Practice Services to be provided pursuant to these Terms
are not covered by any public or private health insurance program (“Insurance Program”).
Notwithstanding the above, you understand and agree to be wholly responsible for the payment of any
and all costs due and that may become due pursuant to these Terms, regardless of the existence of
coverage for such items or services under any Insurance Program.
You understand and agree not to submit a claim, bill to or seek reimbursement from any Insurance
Program for any item or service received pursuant to these Terms. You understand that you will not be
able to appeal any determinations that the Insurance Program will not pay for any item or service received
pursuant to these Terms.
6. MISCELLANEOUS
A. E-mail Communications; Privacy. If you wish to communicate with DPC Practice and its
healthcare providers, staff, employees, agents and representatives (collectively, the “DPC
Practice Care Team”) via e-mail, you should be aware that e-mail is not a secure medium for
sending and receiving potentially sensitive health information. Although DPC Practice will take
steps to keep your communications with the DPC Practice Care Team confidential and secure, the
confidentiality of e-mail communications cannot be assured or guaranteed. You also acknowledge
and understand that e-mail is not a good medium for urgent or time-sensitive communications. In
the event a communication is time-sensitive, you must communicate with DPC Practice Care
Team by telephone or in person. You acknowledge and understand that, at the discretion of DPC
Practice and/or as required by law, your e-mail communications may become part of your
medical record maintained by DPC Practice.
B. Assignment. You may not assign or transfer these Terms, by operation of law or otherwise,
without DPC Practice’s prior written consent. DPC Practice may assign or transfer these Terms, at
its sole discretion, without restriction. Subject to the foregoing, these Terms will bind and inure to
the benefit of the parties, their successors and permitted assigns.
C. Governing Law; Venue. These Terms shall be enforced and construed in accordance with the
laws of the state in which the DPC Practice at which you are a Patient is located (“State”),
without regard to such State’s conflicts of laws provisions.
D. Arbitration and Class Action Waiver. This Section includes an arbitration agreement and an
agreement that all claims will be brought only in an individual capacity. Please read it carefully.
You may opt out of the arbitration agreement by following the opt out procedure described below.
I. Informal Process First. You agree that in the event of any dispute between you and DPC
Practice, you will first contact DPC Practice and make a good faith sustained effort to resolve
the dispute before resorting to more formal means of resolution, including without limitation
any court action.
II. Arbitration Agreement. After the informal dispute resolution process any remaining dispute,
controversy, or claim (collectively, “Claim”) relating in any way to your participation in the
DPC Practice as a Patient and/or your receipt of DPC Practice Services, or relating in any
way to the communications between you and DPC Practice, will be finally resolved by
binding arbitration. This mandatory arbitration agreement applies equally to you and DPC
Practice. You may opt out of this arbitration agreement within thirty (30) days of the Effective
Date by following the procedure described below.
III. You acknowledge and agree that you and DPC Practice are each waiving the right to a trial by
jury or to participate in a class action. This arbitration provision will survive any termination
of these Terms.
IV. If you wish to begin an arbitration proceeding, after following the informal dispute resolution
procedure, you must send a letter requesting arbitration and describing your claim to
Crossover Health Medical Group, APC. 101 W. Avenida Vista Hermosa, Suite 120, San
Clemente, CA 92672. The arbitration will be administered by the American Arbitration
Association (“AAA”) under its rules; payment of all filing, administration and arbitrator fees
will be governed by the AAA's rules.
V. Judgment on the award rendered by the arbitrator may be entered in any court having
jurisdiction thereof.
VI. The arbitrator, and not any federal, state, or local court, will have exclusive authority to
resolve any dispute relating to the interpretation, applicability, unconscionability, arbitrability,
enforceability, or formation of this arbitration agreement, including any claim that all or any
part of this arbitration agreement is void or voidable.
E. Indemnification. You agree to defend, indemnify and hold DPC Practice and its subsidiaries,
affiliates, officers, agents and other partners and employees, harmless from any loss, liability,
claim or demand, including, without limitation, reasonable attorneys’ fees, made by any third
party due to or arising out of your use of the DPC Practice Services in violation of these Terms
and/or arising from a breach of these Terms.
F. No Third-Party Beneficiary. You agree that, except as otherwise expressly provided in these
Terms, there shall be no third party beneficiaries to these Terms.
G. Force Majeure. DPC Practice shall not be deemed in violation of any provision of these Terms if
it is prevented from performing any of its obligations by reason of: (a) severe weather and storms;
(b) earthquakes or other natural occurrences; (c) strikes or other labor unrest; (d) power failures;
(e) nuclear or other civil or military emergencies; (f) acts of legislative, judicial, executive, or
administrative authorities; or (g) any other circumstances that are not within its reasonable
control. This Section shall not apply to obligations imposed under applicable laws and
regulations.
H. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which
affects these Terms, any terms or conditions incorporated by reference in these Terms, the
activities of DPC Practice pursuant to these Terms, or any change in the judicial or administrative
interpretation of any such law regulation or rule, and DPC Practice reasonably believes in good
faith that the change will have a substantial adverse effect on DPC Practice’s rights, obligations or
operations associated with these Terms, then DPC Practice may, upon written notice, revise these
Terms.
I. Severability. If any part, term or provision of these Terms is held by a court of competent
jurisdiction to be illegal or unenforceable, the remaining portions or provisions of these Terms
shall not be affected, and the rights and obligations of you and DPC Practice shall be construed
and enforced as if these Terms did not contain the particular part, term or provision held to be
invalid, unless to do so would contravene the present valid and legal intent of you and DPC
Practice.
J. Waiver. The waiver by you or DPC Practice of a breach of any provisions of these Terms must be
in writing and signed by the waiving party to be effective and shall not operate or be construed as
a waiver of any subsequent breach by either you or DPC Practice.
K. Survival. All provisions of these Terms that by their nature or express terms survive the
expiration or termination of these Terms, shall survive such expiration or termination.
L. Entire Agreement. These Terms, including any exhibits or schedules annexed hereto, constitutes
the entire understanding and agreement between you and DPC Practice with regard to all matters
herein. There are no other agreements, conditions or representations, oral or written, express or
implied, with regard thereto. These Terms supersede, in the entirety, any and all previous
agreements, whether oral or written, between you and DPC Practice concerning the subject matter
hereof.
EXHIBIT A
DPC Practice Services
Package 1:
Primary Care: The member is eligible for one preventative visit and two office visits
Other services: The member is eligible for three visits in any of the services listed below. This is three
visits in aggregate not three visits in each category.
You can substitute any non-primary care visit for a primary care visit. For example, an optometry or
chiropractic visit for a primary care visit.
Service Name Brief Description
Primary Care Health promotion, patient education, diagnosis and
management of acute and chronic illnesses through
routine office visits, urgent care visits, travel
medicine
Preventative Care Disease prevention, health screening and
maintenance through annual well adult exams
Optometry Annual Eye Exams, prescription for glasses or
contact, general eye health
Chiropractic Care Acute care, rehabilitation, injury management and
prevention, pain management
Physical Therapy Acute care, rehabilitation, injury management and
prevention, pain management
Acupuncture Care of for acute and chronic pain, stress and
anxiety, and traditional holistic lifestyle support
Massage Full body massage for stress reduction and
relaxation
Health Coaching Nutrition, fitness, sleep, lifestyle coaching and
support
Behavioral Health Individual therapy, couples counseling, and group/
classes treatment
Package 2:
Primary Care: The member is eligible for one preventative visit and three office visits
Other services: The member is eligible for 8 visits in any of the services listed below. This is three visits
in aggregate not three visits in each category.
You can substitute any non-primary care visit for a primary care visit. For example, an optometry or
chiropractic visit for a primary care visit.
Non-Covered Services:
Service Name Brief Description
Primary Care Health promotion, patient education, diagnosis and
management of acute and chronic illnesses through
routine office visits, urgent care visits, travel
medicine
Preventative Care Disease prevention, health screening and
maintenance through annual well adult exams
Optometry Annual Eye Exams, prescription for glasses or
contact, general eye health
Chiropractic Care Acute care, rehabilitation, injury management and
prevention, pain management
Physical Therapy Acute care, rehabilitation, injury management and
prevention, pain management
Acupuncture Care of for acute and chronic pain, stress and
anxiety, and traditional holistic lifestyle support
Massage Full body massage for stress reduction and
relaxation
Health Coaching Nutrition, fitness, sleep, lifestyle coaching and
support
Behavioral Health Individual therapy, couples counseling, and group/
classes treatment
Service Name Brief Description
Fitness Classes Group HIT Classes
Personal Training 1:1 Exercise training with a coach designed to fit
the specific needs of the individual
Please note that if you wish to use a non-covered service or exceed your visit limits then you are
entitled to as a Crossover Member, however, the fee for service will need to be paid for outside
the monthly fee in accordance with the fee schedule in Exhibit B.
EXHIBIT B
DPC Practice Fee Schedule
Fee for a Service which Exceeds Your Visit Limit Based on Your Selected Package
Package 1 $149.00 per month
Package 2 $275.00 per month
Primary Care $150.00 per visit
Preventative Care $275.00 per visit
Optometry $150.00 per visit
Chiropractic Care $150.00 per visit
Physical Therapy $150.00 per visit
Acupuncture $150.00 per visit
Massage $100.00 per visit
Health Coaching $150.00 per visit
Behavioral Health $150.00 per visit
Fitness Classes $25.00 per visit
Personal Training $65.00 per visit