Entry Date
ROSTER
ONLINE
BILLING

   



Services Provided By:


Get Quote & Enroll

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Select your plan option*
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For your initial payment, you are required to make your initial payment via Debit/Credit Card for the payment required to pay your subscription through the end of the group plan year (December 31st) plus a one-time $10.00 application fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st). Your card will not be charged thereafter and you will be invoiced on an annual basis for payment due January 1st each group plan year. At that time, you will be given the option to pay for your subscription via direct annual bill or via monthly auto pay, automatically draft your bank account on a monthly basis.

MB Telehealth Web Enrollment & Electronic Signature Agreement

Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Member Benefits "sending party", whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.


Paper Copies

You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.


Withdrawal of Consent

You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.


Scope of Consent

You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below. You agree to receive communications from Member Benefits regarding coverage, program availability, and other important updates via email. Your privacy is extremely important to us; we do not sell personally identifiable information to outside parties, and we follow strict security standards. You have the ability to change email delivery preferences and/or opt out at any time. For a full summary of our privacy practices, please visit the Privacy Policy page.


Requesting paper copies, withdrawing consent, and updating contact information

You will have the ability to download and print any documents you complete through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (support@memberbenefits.com) with the following subjects:

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

“Update Contact Information” Please provide your name, email, telephone number and postal address.

IMPORTANT: Your MDLive account will be associated with this address. Please include valid email to agree to conduct business electronically.

Primary Enrollee Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Name*
Mailing Address*

Primary Enrollee Identification

You may add dependent information details once your account is setup with MDLive.

Gender*
Date of Birth*
If an Employee, list your Employer's Member ID#

Payment Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Payment - Initial Payment via Debit/Credit Card

For your initial payment, you are required to make your initial payment via Debit/Credit Card for the payment required to pay your subscription through the end of the group plan year (December 31st) plus a one-time $10.00 application fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st). Your card will not be charged thereafter and you will be invoiced on an annual basis for payment due January 1st each group plan year. At that time, you will be given the option to pay for your subscription via direct annual bill or via monthly auto pay, automatically draft your bank account on a monthly basis.


Effective Date
Your service is to be made effective on the 1st day of the month following your enrollment date and after receipt of your initial premium payment.
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Required payment to pay for subscription up through the end of the plan year (Dec 31st) + $10.00 Application Fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).
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One Time Credit Card Payment Authorization*

IMPORTANT:

Please note, premium billing for this plan is administered by the plan administrator Member Benefits. Please make sure to recognize us on your credit card statement as:  

Member Benefits

Enrollment/Membership Agreement

Member Benefits Teleheath Membership Enrollment Agreement*
Use your mouse or finger to draw your signature above
Year End
Entry Month