ALL - Telehealth Enrollment

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.

Email*

Confirm Email *

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.

Applying As:

Name*

First Name

Initial (optional)

Last Name

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Primary Enrollee Identification

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

Gender*

Male Female

Date of Birth*

Member Name

Occupation

Employer Name (if employed)

Association Member ID#

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 $20.00 enrollment processing 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.

Initial Subscription Payment Required: $

Required payment to pay for subscription up through the end of the plan year (Dec 31st) + $20.00 one-time processing 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).

Processing Fee $

Credit Card*

One Time Credit Card Payment Authorization*

I hereby authorize Member Benefits to make a one time debit to my credit card listed above for the Initial Subscription Payment Required. By agreeing, I give permission to immediately debit my account upon completion of my online enrollment. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to my account. I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the service described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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*

I hereby apply for the MB TELEHEALTH, a service made available by Member Benefits and MD Live, for which I am eligible through my association. To the best of my knowledge and belief, the information I’ve provided is complete and correct. I understand I am a participant in a group program and the plan provider, costs, service fees, eligibility requirements, and benefits may change. I have read and understand the conditions and plan limitations as described in the plan information through this website. I understand my service will end if my eligibility cannot be confirmed or if any required payment is not received or reversed by my bank. I understand that services will become effective on the next available enrollment date following approval of my enrollment and confirmation of my eligibility for this program. I understand and agree that I have made my plan election and selected my covered dependents for the plan year, up through December 31st. My elections are fixed up to the next annual open enrollment date (January 1st), after which time my continued enrollment and plan elections for the next plan year will be automatic unless written notice of a requested change or termination is received by Member Benefits prior to the next annual open enrollment date (January 1st). I understand if I terminate this coverage or discontinue enrollment for any reason, I will not be permitted to re-enroll in this plan for a period of 24 months from the effective date of my coverage termination. I understand once my enrollment has been approved, I will have access to create an account with MD Live in order to utlize this service. I understand MD Live charges additional fees for certain services when utilizing this benefit. MD Live is not available in all states. MD Live does not replace the primary care physician. MD Live does not guarantee that a prescription will be written. MD Live operates subject to state regulation and may not be available in certain states. MD Live does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MD Live physicians reserve the right to deny care for potential misuse of services. I understand that my service will be activated after approval of my enrollment form, receipt of any required initial payment, and sufficient administrative processing time of 3-5 business days. I understand a refund of payment may be requested if service is terminated within 30 days of my application and if service has not been utilized, otherwise all monies paid are non-refundable. I understand all coverage changes and cancellation requests must be submitted, in writing or through the appropriate web form, directly to the plan administrator, Member Benefits. Change or cancellation requests submitted directly to MDLive will not be honored.

Signature*

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