Passion Health Direct
Membership Agreement, Enrollment Form and Recurring Payment Authorization
Plan - $255 paid in advance for the first three months; then $85 per Member per month
Important required disclosure
THIS DIRECT PATIENT CARE AGREEMENT IS NOT HEALTH INSURANCE.
It does not replace comprehensive health insurance and does not cover hospital care, emergency care, specialists, prescriptions, or services furnished by outside providers. You are strongly encouraged to maintain insurance for services not included in this Agreement and for major medical expenses.
This notice is provided before enrollment as required by Texas Occupations Code Chapter 117.
IMPORTANT HSA DISCLOSURE
Passion Health Direct is not represented or intended to qualify as an HSA-compatible direct primary care service arrangement. Enrollment may affect the Member's eligibility to make or receive contributions to a Health Savings Account. The Practice does not accept HSA or FSA cards for recurring membership fees. The Member should consult an HSA custodian, benefits administrator, or tax adviser before enrolling.
Member initials acknowledging this disclosure:
This notice is provided before enrollment as required by Texas Occupations Code Chapter 117.
1. Parties and purpose
This Membership Agreement ("Agreement") is between PHP INS TX PLLC d/b/a Passion Health Direct ("Practice") and the person identified in Appendix B ("Member"). If the Member is a minor or lacks legal capacity, the parent, guardian, or legal representative signing this Agreement acts on the Member's behalf.
This Agreement covers only the individual Member identified in Appendix B. A separate Membership Agreement is required for each additional patient, including each child or dependent, even when the same account holder pays for more than one patient.
The Agreement describes direct patient care services provided in exchange for a recurring direct fee. It applies only to the membership services expressly listed in Appendix A. Membership is with the Practice as a whole, not with any particular physician or other practitioner. The Practice may provide care through appropriately licensed physicians and health care practitioners and may assign or change the clinician or care team based on availability, location, clinical needs, and scope of practice.
2. Eligibility, acceptance and term
1. The program is available only to self-pay Members who are uninsured or for whom the Practice and every participating clinician, tax identification number, and location that may furnish included membership services are out of network under the Member's commercial health plan. A patient is not eligible if any potentially assigned membership provider is in network for the included services.
2. The Member must accurately disclose insurance and federal health-program status. Unless the Practice provides written clearance and any separately required contract, this program is not available to a person enrolled in or entitled to Medicare, Medicaid, TRICARE, or another government program that restricts private payment for covered services.
3. The Agreement begins on the Effective Date shown in Appendix B after both parties sign, the initial $255 payment per enrolled Member is successfully processed, and the Practice accepts enrollment. The initial payment covers the first three months. Beginning with month four, the Agreement continues month to month at $85 per enrolled Member per month until terminated under Section 12.
4. This Agreement does not apply to workers' compensation services or claims.
5. Enrollment and termination decisions will be based on service capacity, lawful scope of practice, insurance-network status, payment eligibility, safety, and other legitimate nondiscriminatory criteria. The Practice will not discriminate on a basis prohibited by applicable law.
3. Membership services
The membership fee covers the services listed as included in Appendix A when the Practice determines they are medically appropriate, within the clinician's lawful scope and capabilities, and provided at a participating Passion Health Direct location or through an approved telehealth channel. Membership is not an unlimited-use entitlement and does not require a clinician to order, prescribe, refer, certify, or perform a service that is not clinically appropriate.
Because membership is with the Practice as a whole, the Practice will use reasonable efforts to route each care request to an appropriately licensed physician, practitioner, or care-team member who is immediately available or, if no one is immediately available, next available to address the Member's clinical needs. The assigned clinician may vary based on urgency, location, staffing, availability, and scope of practice. The Member may request a particular clinician, but access to that clinician and same-day or next-day service are not guaranteed.
4. Services and costs not included
• Emergency department, ambulance, hospital, surgery-center, inpatient, or urgent-care services furnished outside the Practice.
• Conditions requiring chronic schedule II medications
• Specialist, dental, vision, behavioral-health, home-health, rehabilitation, or other outside professional services unless expressly listed as included.
• Prescription and over-the-counter drugs, vaccines, injectable medications, durable medical equipment, supplies, pathology, outside laboratory testing, and outside imaging.
• Procedures, forms, records, administrative services, travel, house calls, worksite visits, or occupational-health services not expressly listed as included.
• Any service separately identified in advance as subject to a self-pay fee or governed by another Passion Health financial policy.
The Member may decline any separately priced service. The Practice will disclose its charge before providing a separately priced service when required by law and will provide a good faith estimate to an uninsured or self-pay Member when applicable. Charges from outside providers are set and collected by those providers and are the Member's responsibility.
5. Membership fee and advance billing
Initial membership payment - $255 per enrolled Member, paid in advance, covering the first three months
Ongoing membership fee - $85 per enrolled Member per month beginning with month four
Billing frequency - Initial $255 payment in advance; monthly billing thereafter on the billing date selected in Appendix C
Enrollment fee - $0 unless a separate written enrollment summary signed by the Member states otherwise
Other charges - Not included in recurring authorization; separately disclosed and authorized at the time of service
The Member authorizes recurring payment through Appendix C. If a payment fails, the Practice may notify the Member and request a replacement payment method. After a reasonable opportunity to cure, the Practice may suspend non-urgent membership privileges or terminate the Agreement in a manner consistent with applicable law and appropriate continuity-of-care obligations.
The Practice will not retroactively calculate or collect the fee-for-service value of previously included services solely because the Member cancels. Refunds at termination are governed by Section 12.
6. Insurance and third-party payment
The Practice will not bill an insurer or health maintenance organization for direct patient care paid under this Agreement. The Member will not ask the Practice to submit claims for included services. The Practice can provide a receipt for membership payments.
This Agreement is intentionally not represented or intended to qualify as an HSA-compatible direct primary care service arrangement. Enrollment may affect the Member's eligibility to make or receive HSA contributions. The Practice will not process an HSA or FSA card for recurring membership fees. The Member must use a regular ACH account, debit card, or credit card for recurring membership payments.
The Member is solely responsible for determining any tax, HSA, FSA, benefits, or reimbursement consequences of enrollment and should consult the Member's account custodian, plan administrator, benefits adviser, or tax adviser before enrolling. A receipt provided by the Practice does not establish that a payment is tax-free, deductible, eligible, or reimbursable.
Passion Health may offer services outside this Agreement through separate departments, entities, locations, or financial policies. Those services may be self-pay or may be billed to insurance when permitted and separately agreed. They are not included merely because the Member is enrolled in Passion Health Direct.
The Practice does not provide tax, benefits, or reimbursement advice and does not guarantee any particular tax or reimbursement treatment.
7. Medicare, Medicaid, TRICARE and other government programs
The Member must notify the Practice immediately if the Member becomes enrolled in or entitled to Medicare, Medicaid, TRICARE, or another government program during the membership. The Practice may pause services or terminate this Agreement if necessary to comply with program rules. A Medicare beneficiary may receive covered services under a private-pay arrangement only when the treating physician or practitioner has satisfied federal opt-out and private-contract requirements; this membership form is not a Medicare private contract.
8. Appointments, communications and emergencies
1. Membership does not provide 24-hour continuous monitoring or guarantee an immediate response. Routine portal, email, text, and telephone messages should be used only as instructed by the Practice.
2. Electronic communications may have privacy and security risks. The Member may choose communication preferences in Appendix B and may change or revoke an optional preference prospectively by notifying the Practice. Revocation will not affect communications required or permitted by law.
3. Email, text, voicemail, portal messages, and telehealth are not appropriate for emergencies. For an emergency or potentially life-threatening problem, call 911 or go to the nearest emergency department.
4. Technical failure, power loss, service interruption, or clinician absence may delay communication or require rescheduling. The Practice will use reasonable efforts to notify affected Members and arrange appropriate alternatives, but outside care is not included in the membership fee.
5. Before receiving telemedicine or telehealth services, the Member or legal representative must complete any separate informed-consent process required by the Practice or applicable law. The Member must accurately disclose the Member's physical location at the time of each remote encounter.
9. Clinical judgment and controlled substances
All diagnosis, treatment, testing, referrals, prescriptions, and procedures remain subject to independent clinical judgment, professional standards, licensing rules, and applicable law. Membership does not guarantee a prescription, controlled substance, work restriction, disability certification, referral, test, procedure, or specific clinical outcome. The Practice does not provide chronic pain-management services or ongoing controlled-substance prescribing unless expressly accepted under a separate clinical policy.
10. Privacy and records
The Practice's Notice of Privacy Practices governs the use and disclosure of protected health information. The Member may request access to records as permitted by law. Standard record-copying, form, or transfer charges may apply only when permitted by law and disclosed under the applicable Practice policy. Signing this Agreement does not waive privacy rights or the right to complain to a regulator.
11. Member responsibilities
• Provide complete and accurate medical, contact, insurance, and payment information and promptly report changes.
• Use services respectfully and safely, follow scheduling and communication policies, and avoid threatening, abusive, fraudulent, or disruptive conduct.
• Keep appropriate health insurance for services not included and understand the Member's own coverage, deductibles, networks, and benefits.
• Pay separately disclosed charges for non-included services and charges from outside providers.
• Seek emergency care promptly when appropriate and not rely on membership communications for emergencies.
12. Termination and refunds
1. The Member may cancel at any time by written notice. Cancellation is effective on the requested date or, if no later date is requested, at the end of the current paid membership period. To avoid the next automatic debit, the Member should provide notice at least three business days before the scheduled billing date.
2. The Practice may terminate without cause on at least 30 days' written notice. It may terminate sooner when permitted by law for nonpayment, fraud, misuse of services, safety threats, material breach, loss of eligibility, or legal/regulatory necessity, while observing applicable continuity-of-care and patient-abandonment requirements.
3. The initial $255 payment consists of three prepaid monthly membership periods of $85 each. The Practice will refund any membership fee collected for a full prepaid monthly period after the effective termination date. For a partial monthly period, the Practice will refund the unearned portion when the Practice terminates without cause or when otherwise required by law. No refund is due for a completed monthly period solely because the Member did not use services.
4. Termination automatically ends future recurring-payment authority after charges already initiated before the effective revocation date have been processed. The Member remains responsible for separately authorized charges incurred before termination.
13. Changes to fees or services
The Practice may change the membership fee, included services, participating locations, or program policies by giving at least 60 days' written notice unless a shorter change is required by law or necessary for safety. If the Member does not accept a material change, the Member may terminate before the change takes effect.
14. Concerns and complaints
The Practice encourages the Member to raise concerns promptly through the membership contact listed in Appendix B so the parties can attempt to resolve them. Nothing in this Agreement restricts truthful reviews, reports to licensing boards or government agencies, participation in investigations, consultation with counsel, or any other non-waivable right.
15. General terms
Texas law governs this Agreement. Any court proceeding shall be brought in a court with lawful jurisdiction and venue. If a provision is unenforceable, it will be limited or severed only to the extent necessary, and the remaining provisions will continue. This Agreement, including its appendices and any signed enrollment summary, is the entire agreement regarding Passion Health Direct membership and may be amended only in writing as provided here. Delay in enforcement is not a waiver. The Member may not assign the membership. Electronic signatures and counterparts are permitted.
Notices may be sent to the latest mailing address or email address provided by the receiving party. Practice notice information: 230 O Connor Ridge Blvd, Suite 110, Irving, TX 75038; email: appointments@passionhealthphysicians.com; telephone: 214-666-6259.
16. Acknowledgment and signatures
By signing, the Member confirms that the Member received the required notice that this Agreement is not insurance before entering the Agreement; understands that the Agreement is not represented or intended to be HSA-compatible and may affect HSA contribution eligibility; reviewed the included, excluded, and separately priced services; had an opportunity to ask questions; received or will receive a copy of the signed Agreement and payment authorization; and agrees to the terms above.
Appendix A - Membership services
Services are included only when clinically appropriate, available at a participating location, within the treating clinician's scope, and not identified below as separately priced.
Included primary care services
• Scheduled primary care office visits and approved telehealth visits during published program hours, subject to reasonable-use and scheduling policies.
• Evaluation and management of common acute illnesses and minor injuries appropriate for an outpatient primary care setting.
• Ongoing management of common chronic conditions such as hypertension, diabetes, asthma, and thyroid disease.
• Annual preventive examination and age-appropriate preventive counseling, excluding outside tests, vaccines, medications, and procedures.
• Medication review, routine prescription management, and refill review when clinically appropriate; medication cost is not included.
• Review of available test results and coordination of referrals to outside specialists when appropriate; outside provider fees are not included.
• Basic in-office clinical evaluation and monitoring when available and clinically appropriate, which may include blood-pressure monitoring, simple wound assessment, and simple suture or staple removal. Tests, supplies, medications, procedures, and professional interpretations - including urinalysis, rapid strep testing, EKG, spirometry, nebulizer medication or supplies, and ear lavage - are separately priced unless the Practice's written service schedule expressly states otherwise.
• Routine secure messaging and telephone guidance during designated program hours, subject to response-time and communication policies.
Member pricing benefits
Eligible Passion Health in-house laboratory and imaging services purchased on a self-pay basis receive a 20% discount from the then-current Passion Health self-pay cash price. The discount does not apply to insurance-billed services, third-party charges, outside interpretations, send-out services priced by another vendor, prior balances, packages, or services prohibited from discounting by contract or law. Availability and pricing may vary by location and service.
Eligible services furnished by participating specialists within Passion Health and purchased on a self-pay basis receive a 20% discount from the then-current Passion Health self-pay cash price. Specialist services are not included in the membership fee and are provided under separate financial arrangements. The discount does not apply to insurance-billed services, facility charges, third-party charges, outside professional interpretations, excluded procedures or packages, prior balances, or services prohibited from discounting by contract or law. Availability varies by specialty, clinician, location, and service.
Member pricing is a separate self-pay benefit and is not an included membership service, insurance benefit, guarantee of availability, or promise of referral. The Member remains free to use any laboratory, imaging provider, or specialist, and clinical recommendations will not be conditioned on the Member's use of Passion Health services. Each discounted service requires separate disclosure, consent, and payment and will not be billed to insurance.
Not included
• Emergency, hospital, facility, specialist, ambulance, and outside-provider services.
• Medication, vaccine, injectable, supply, device, laboratory, imaging, pathology, and interpretation costs unless expressly stated as included in writing.
• Ongoing controlled-substance management, chronic pain management, or services outside primary care scope.
• House calls, worksite visits, occupational medicine, workers' compensation, immigration exams, disability evaluations, and extensive forms unless separately scheduled and priced.
• Any service not listed as included or identified in advance as separately priced.
Appendix B - Member enrollment and preferences
ELIGIBILITY ATTESTATION
I am uninsured.
I have commercial health coverage, and the Practice has determined that every potentially assigned membership provider, tax identification number, and participating location is out of network for the included services.
I am not currently enrolled in or entitled to Medicare, Medicaid, TRICARE, or another government program that restricts private payment for covered services.
I will promptly notify the Practice if my coverage or eligibility changes.
HSA AND FSA ACKNOWLEDGMENT
I understand that Passion Health Direct is not represented or intended to be HSA-compatible and that enrollment may affect my eligibility to make or receive HSA contributions.
I understand that the Practice will not accept an HSA or FSA card for recurring membership fees and does not provide tax or benefits advice.
PRIVACY NOTICE ACKNOWLEDGMENT
I received, or will receive no later than the first service delivery, the Practice's Notice of Privacy Practices.
COMMUNICATION PREFERENCES
YES, I consent to routine email communication at the address above, understanding ordinary email may not be fully secure.
NO, do not use ordinary email for optional communications; use the patient portal or telephone when available.
YES, I consent to routine text messages at the mobile number above, which may include appointment, billing, and care-related information.
NO, do not send optional text messages; legally required or emergency communications may still be made as permitted.
I understand that email and text are not monitored continuously and must not be used for emergencies. I may revoke an optional communication preference prospectively by notifying the Practice.
ENROLLMENT SUMMARY
**Initial membership payment **- $255 per Member, paid in advance for the first three months
Ongoing monthly fee - $85 per Member beginning with month four
Appendix C - Recurring payment authorization
Complete this authorization only after reviewing the initial and ongoing membership amounts and billing dates. The authorization applies only to the fixed membership charges shown below. Other services and incidental charges require separate disclosure and authorization.
RECURRING AMOUNT
Initial debit - $255, paid in advance for the first three monthly periods
Ongoing monthly debit - $85 beginning with month four
Regular debit or credit card enrolled securely. HSA and FSA cards are not accepted for recurring membership fees.
For security, do not write the complete card number or card security code on this form.
AUTHORIZATION TERMS
1. I authorize an initial debit of $255 for this Member's first three monthly membership periods, followed by $85 each month beginning with month four, and any credit needed to correct an error.
2. This authorization does not cover incidental or non-membership charges, including any separately priced service or no-show fee, which require separate disclosure and authorization.
3. Changing either membership payment amount requires updated written authorization.
4. I may revoke this authorization by written notice to the Practice. To allow processing before the next scheduled debit, I should give notice at least three business days in advance. Revocation does not affect a debit already initiated or an amount I otherwise owe.
5. I may exercise any additional stop-payment, error-resolution, and consumer rights available under applicable law and my financial institution's rules.
6. I certify that I am an authorized signer or cardholder for the payment method and will notify the Practice if the payment information changes.
A copy of this signed authorization must be provided to the account holder. Store payment information only in the Practice's approved secure system.
