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DIRECT CARE INDIVIDUAL MEMBERSHIP TERMS OF SERVICE

These Terms were last updated on June 1, 2024.

Agreement to the Terms of Service

These Pivotal Health Direct Care Individual Membership Terms of Service (“Terms”), which includes an agreement to arbitrate and consent to electronic communications, govern your access to and use of services provided by Pivotal Health, Inc. (“Pivotal Health”, “Practice”, “we”, “us”, or “our”), including the Pivotal Health website located at  www.pivotalhealth.care, the Pivotal Health mobile application, membership services that include personal healthcare navigation services, wellness services, communication services, facilitation of access to telehealth services, including certain on-demand app and video-based telehealth services, and other technology-enabled or personal services provided by Pivotal health or its affiliate (collectively, the “Services”).

Please read these Terms carefully before using the Services. By accessing or using the Services you (“Patient”) agree to be bound by these Terms. If you accept or use Services for another person (“Family Member”) as such Family Member’s parent, guardian, conservator, or custodian, you agree to the terms, conditions, and notices contained or referenced herein the Terms on behalf of such Family Member.

  1. MEMBERSHIP. Patient hereby agrees to enroll as a member in the Practice’s direct urgent and primary care membership program (“Membership Program”) beginning on the Effective Date of your Membership. By being a member of the program, Patient shall be eligible to receive certain medical services described on Exhibit A (“Membership Services”), attached hereto and made a part hereof, and shall be subject to the conditions and limitations described therein. Membership in the Practice’s Membership Program includes only the Membership Services specifically described in Exhibit A. The Practice may add or discontinue Membership Services at any time, as it may choose in its sole discretion. The Practice shall provide at least sixty (60) days’ advance written notice upon any change to the Membership Services listed in Exhibit A.
  2. MEMBERSHIP FEES. The Patient agrees to pay a monthly, semester or annual fee (“Membership Fee”) in accordance with the published pricing. Monthly Membership Fees shall be due on the first day of each month following the Effective Date and will cover the Patient’s membership for that month. Any fees or charges that are not included in the Membership Fee (i.e. fees for non-covered services) shall be due at the time of service. For purposes of this Membership Agreement, “Family” includes only legal dependents and is limited to two (2) adults.
    1. CREDIT / DEBIT CARD. The monthly payment must be made by a credit or debit card that will be kept on file by the Practice.
    2. If the Patient is unable to pay the monthly Membership Fee in full and on time, the Practice may, in its sole discretion, terminate this Membership Agreement in accordance with section 5A. It is the Patient’s responsibility to maintain a correct and up-to-date credit/debit card number on file.
    3. CHANGES TO MEMBERSHIP FEE SCHEDULE. The Practice may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least 60 days’ advance written notice. The Patient may terminate their membership if the Fee Schedule is changed. Any prepaid Membership Fees will be promptly refunded to the Patient in that case.
  3. NON-COVERED SERVICES. Patient understands and acknowledges that Patient is responsible for any charges incurred for health care services performed not performed by the Practice including, but not limited to, emergency room visits, hospital and specialist care, and radiology performed by third parties. Patient shall also be responsible for any charges incurred for health care services provided by the Practice but not specifically described on Exhibit A. The Practice strongly encourages the Patient to maintain health insurance during the term of this Membership Agreement to cover services that are not provided under this Membership Agreement. It is recommended that the Patient should purchase health insurance to cover, at a minimum unpredictable and catastrophic expenses.
  4. Patient acknowledges and understands that the Membership Agreement or Membership in the Practice does not provide comprehensive health insurance coverage, nor is it a contract of insurance.
    1. INSURANCE CLAIMS. Patient acknowledges and understands that the Practice is not a participating provider in any Medicaid or private health care plan. Patient acknowledges and understands that the Practice will not bill insurance carriers on Patient’s behalf for Covered Services provided to Patient and the Practice will not bill any health care plan of which the Patient may be a subscriber or beneficiary for Membership Fees due and owing to the Practice under this Membership Agreement. Membership Fees may not be submitted to insurance companies for reimbursement.
    2. TAX-ADVANTAGED MEDICAL SAVINGS ACCOUNTS. As of the date hereof, it is unlikely that the Membership Fees described in Section 2 constitute eligible medical expenses that are payable or reimbursable using a tax-advantaged savings account such as a health savings account (“HSA”), medical savings account (“MSA”), flexible spending arrangement (“FSA”), health reimbursement arrangement (“HRA”), or other health plans similar thereto (collectively referred to as a “tax-advantaged savings account”). Every health plan is uniquely different. Patient should consult with their health benefits advisor regarding whether Membership Fees may be paid using funds contained in Patient’s tax-advantaged savings account, as may be applicable.
    3. HEALTH PLANS. Because the Practice is not a participating provider in any Medicaid or private health care plan, third party payers may not count the Membership Fees incurred pursuant to this Membership Agreement toward any deductible Patient may have under a health plan. Patient should consult with their health benefits advisor regarding whether Membership Fees may be counted toward the Patient’s deductible under a health plan, as may be applicable.
  5. TERMINATION OF AGREEMENT. Termination of this Membership Agreement shall cause the termination of Patient’s membership in the Membership Program described herein.
    1. TERMINATION BY PRACTICE. The Practice may terminate this Membership Agreement upon providing Patient advance written notice. Termination will be effective starting five business days after notification. Upon termination, the Practice shall comply with all rules and regulations of the State of Wisconsin Medical Board regarding the provision of emergent care for 30 days after termination and cooperate in the transfer of Patient’s medical records to the Patient’s new primary care physician, upon the Patient’s written request and direction.
    2. TERMINATION BY PATIENT. Patient commits to the Membership Term. If the Patient purchases a Monthly membership, the Patient is committing to a 12-month Membership Term.
  6. In the event Patient terminates this Membership Agreement after the Effective Date hereof, Patient shall be ineligible for membership for a period of six (6) months following the effective date of termination, unless Patient pays a fee in the amount of four hundred dollars ($400.00) (“Reinstatement Fee”).
  7. Patient agrees to indemnify and to hold the Practice and its members, officers, directors, agents, and employees harmless from and against all demands, claims, actions or causes of action, assessments, losses, damages, liabilities, costs and expenses, including interest, penalties, attorney fees, etc. which are imposed upon or incurred by the Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.
  8. ENTIRE AGREEMENT. This Membership Agreement constitutes the entire understanding between the parties hereto relating to the matters herein contained and shall not be modified or amended except in a writing signed by both parties hereto.
  9. The waiver of either the Practice or Patient of a breach of any provisions of this Membership Agreement 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 the Practice or Patient.
  10. CHANGE OF LAW. If there is a change of any law, regulation or rule, federal, state or local, which affects this Membership Agreement, any terms or conditions incorporated by reference in this Membership Agreement, the activities of the Practice under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and the Practice reasonably believes in good faith that the change will have a substantial adverse effect on the Practice’s rights, obligations or operations associated with this Membership Agreement, then the Practice may, upon written notice, require the Patient to enter into good faith negotiations to renegotiate the terms of this Membership Agreement. If the parties are unable to reach an agreement concerning the modification of this Membership Agreement within ten (10) days after the effective date of change, then the Practice may immediately terminate this Membership Agreement upon providing written notice to the Patient.
  11. GOVERNING LAW. This Agreement and the rights and obligations of the Practice and Patient hereunder shall be construed and enforced pursuant to the laws of the State of Wisconsin.
  12. ASSIGNMENT/BINDING EFFECT. This Membership Agreement shall be binding upon and shall inure to the benefit of both the Practice and Patient and their respective successors, heirs and legal representatives. Neither this Membership Agreement, nor any rights hereunder, may be assigned by the Patient without the written consent of the Practice.

 

Exhibit A – Membership Services

 

  1. Available Hours and Days:
    1. Pivotal Health is available on Monday through Friday from 8:00 am central to 8:00 pm central and Saturday and Sunday from 10:00 am central to 7:00 pm central.
    2. Pivotal Health may shorten hours in the summer (between Memorial Day and Labor Day). Please note that hazardous weather, or other conditions,  may cause Pivotal Health to temporarily change these hours.
  2. Holidays: Pivotal Health is typically closed on these holidays including New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas Eve, and Christmas.
  3. Service Areas: As of the date of this agreement, Pivotal Health will see patients in homes, apartments, dorm rooms, offices, job sites, or other suitable locations within the following metro areas and counties in Wisconsin and is subject to change:
    1. Madison Metro – Dane County and parts of Columbia and Sauk Counties.
    2. Northeast Wisconsin (Green Bay/Appleton and Oshkosh/Fond du Lac) – Brown, Outagamie, Winnebago, Fond du Lac, Calumet, and Green Lake Counties. Parts of Dodge and Kewaunee Counties.
  4. Scheduling Methods: Members should schedule with the Pivotal Health mobile app which is available for both Apple and Android devices. Members can also schedule visits by calling Pivotal Health at 888-688-4746 during open hours.
  5. Services Included in the Membership.
    1. Unlimited Urgent Care Services, Primary Care Services, Chronic Disease Management, and Included Lab service visits as defined below.
    2. Welcome / Orientation Visit including:
      1. Annual Laboratory Workup
        1. Complete Blood Count: Platelet, RBC, WBC, Hemoglobin, Hematocrit
        2. Lipid Profile: Total Cholesterol, Triglycerides, HDL, LDL, Ratio
        3. Complete Metabolic Panel: Glucose, Calcium, Sodium, Potassium
        4. Hemoglobin A1C (HgbA1c)
        5. Thyroid Studies: TSH, Free T4 and Free T3
        6. Prostate Specific Antigen (male)
      2. Review of medical history
    3. Urgent Care Services means medically necessary healthcare services for a condition that requires prompt medical attention but is not an Emergency Medical Condition as defined below. Pivotal Health’s Individual Providers can also electronically send prescriptions to the pharmacy of the patient’s choice. Examples of Urgent Care Services include, but are not limited to, the assessment and treatment of:
      1. Respiratory conditions and infections including flu, strep throat, sinus infections, ear infections, pharyngitis, pneumonia, bloody noses, RSV infections, and Covid-19
      2. Gastrointestinal and abdominal conditions including abdominal pain, nausea/vomiting, food poisoning, heartburn, diarrhea, constipation, and dehydration
      3. Eye conditions including infections, styes, and certain corneal abrasions
      4. Genitourinary conditions including urinary tract infections, sexually transmitted diseases, vaginal discharge, and breast infections.
      5. Skin conditions or injuries including lacerations, cellulitis, wounds, and rashes
      6. Muscle, joint, and bone injuries including sprains and strains. Radiology services are not covered under this Agreement.
      7. Neurological conditions including migraines, dizziness, and vertigo

    4. Primary Care or Preventive Care Services include:
      1. Adult (18+) wellness exams and physicals
      2. Health risk assessments
      3. DOT physicals
      4. Sexual / reproductive health
      5. Flu shots
      6. Medication management assistance
      7. Sports / School / Camp physicals for patients under 18

    5. Included Lab Services. The following lab services are included in the membership.
      1. Rapid tests for Covid, flu, strep, RSV and more
      2. Rapid urine tests including urine dipstick
      3. BMP
      4. CBC w/differential + platelet
      5. Chlamydia, gonorrhoeae, trichomonas vaginalis, and other STD tests
      6. CMP
      7. Creatinine
      8. HbA1c
      9. Hep C Tests
      10. Hepatic Function Panel
      11. Iron Panel
      12. Lipase
      13. Lipid panel (fasting & non fasting)
      14. Liver Function Test (LFT)
      15. Mononucleosis
      16. Potassium
      17. PSA Screen
      18. Pregnancy urine test
      19. Urine microalbumin
      20. T4/T3
      21. TSH
      22. TSH, Rfx on abnormal to Free T4
      23. Urine culture and urinalysis
      24. Vitamin D
    6. Other labs at Pivotal Health’s wholesale cost
    7. Chronic Disease Management for the diseases listed below
      1. Diabetes
      2. High Blood Pressure
      3. High Cholesterol
      4. Hypothyroidism
      5. Asthma
      6. Chronic Obstructive Pulmonary Disease (COPD)
      7. Reflux Disease (GERD)
      8. Depression/Anxiety
      9. Migraines
      10. Acne
      11. Birth control / sexual health
      12. Smoking cessation
      13. Osteoarthritis
      14. Gout
  1. Services not included
    1. Any care delivered by providers not affiliated with Pivotal Health.
    2. Radiology – X-rays, CT scans, MRIs, ultrasounds, and EKGs. Pivotal Health can make referrals for these services if needed to various radiology practices.
    3. Treatment of Emergency Conditions. Emergency Conditions are defined as illnesses, injuries, symptoms (including severe pain), or conditions so serious that a reasonable person would seek care right away to avoid severe harm. Pivotal Health does not treat some Emergency Medical Conditions including heart attacks, strokes, severe broken bones, appendicitis, or conditions that require oxygen tanks. If a patient believes they potentially have an Emergency Medical Condition, they should immediately go to an Emergency Room or call emergency services at 9-1-1. Patients can call Pivotal Health to determine if their condition is suitable for a Pivotal Health house call visit.
    4. Durable Medical Equipment is not included including braces, splints, and crutches. The patient will be charged 120% of our wholesale cost if these items are needed.