As part of the sign-up process, you will be asked below to include payment information. This way, if you choose to extend, your coverage may continue without interruption. Be assured: you will not be charged now. We will email you prior to the end of the funded telehealth benefit and you will be given the opportunity to opt-out. If you wish to continue, take no action and your coverage will remain in place. Simply put: you can sign up for this offer in confidence, knowing that you may cancel at any time, no questions asked. For program cost information, please review the Plan Details.

Billing Address is same as Residence Address

INSURANCETPA.COM TELEHEALTH ENROLLMENT AGREEMENT InsuranceTPA.com provides instant enrollment with a Telehealth Provider Partner that offers telehealth services (the "Telehealth Services") in your region. The terms and conditions in this InsuranceTPA.com Telehealth Enrollment Agreement and those described elsewhere on this website apply to the telehealth enrollment and payment process. Applicant's Request to Enroll A. Electronic Enrollment Application By submitting this electronic Enrollment Application to use the Telehealth Services provided by your InsuranceTPA.com Telehealth Provider Partner, the Applicant represents that s/he has the legal authority to complete the Enrollment Application for each enrolled individual and that the information provided in the Enrollment Application is true and correct. The Applicant acknowledges and agrees to comply with the InsuranceTPA.com Telehealth Administration Process Terms and Conditions found here www.insurancetpa.com/telehealth-terms/ and understands and agrees to the terms of the InsuranceTPA.com Privacy Policy www.insurancetpa.com/privacypolicy/ B. Payment Authorization The Applicant authorizes the online telehealth enrollment administrator InsuranceTPA.com to charge the Applicant's Payment Method in the agreed amount for the Services until the Applicant requests cancellation in writing. The Applicant understands and agrees that five (5) calendar days' written notice is required to end the payment authorization. Requests to end payment authorization that occur less than five calendar (5) days from the scheduled payment date will end payment on the next scheduled payment date. Per the InsuranceTPA.com Telehealth Administration Process Terms and Conditions, the Telehealth Provider Network may increase, decrease or otherwise adjust the cost of the Telehealth Services at its discretion with thirty (30) days' advance electronic notice to the enrolled participant. C. Cancellation An enrolled telehealth participant may cancel enrollment at any time by providing written notice of cancellation to InsuranceTPA.com (email accepted at service@insurancetpa.com). Cancellation will terminate enrollment for the enrolled participant and also automatically for the spouse and each dependent who was listed on the Application and enrolled with the participant. After cancellation, re-enrollment for any cancelled participant, spouse or dependent will be available after a 12-month waiting period has passed from the most recent date of cancellation. D. Service Fee The applicable Telehealth Provider Partner may, at its discretion, provide the Telehealth Services at a cost that is subsidized through an insurance broker to ensure a competitive price for participants. InsuranceTPA.com may also remit a royalty to the Telehealth Provider for the Telehealth Services. E. Not a Medical Provider, Not Insurance InsuranceTPA.com is an online portal administrator that enrolls participants with the applicable Telehealth Provider Partner for the participant's geographic location. InsuranceTPA.com is not a medical provider and is not health insurance. InsuranceTPA.com does not endorse any health care provider or facilitate health care. The Telehealth Providers are subject to state regulation. Certain Telehealth Providers may not be available in every state. The Telehealth Providers offered through InsuranceTPA.com do not prescribe DEA controlled substances, non-therapeutic drugs or other substances that may be harmful because of their potential for abuse. Current Price Schedule InsuranceTPA.com is providing participant access to its Telehealth Provider Partners at no cost to the participant for two (2) consecutive months after the participant's enrollment date. This program is provided exclusively to individuals and families who enroll with a Telehealth Provider Partner that is offered through InsuranceTPA.com. The discount is offered to help connect participants with medical and health services during this challenging time. The participant's enrollment with the Telehealth Provider Partner will automatically continue after two (2) consecutive months, at which time the Service fee will be directly billed to the participant's Payment Method for participation in the third month and monthly thereafter subject to cancellation as described in this enrollment application and the applicable terms and conditions.

Enrollment and Electronic Signature

  I agree to enroll in MDLive TeleHealth provided by InsuranceTPA.com. I have read and agree to the terms of the InsuranceTPA.com TeleHealth Enrollment Agreement. By agreeing to enroll in MDLive Telehealth provided by InsuranceTPA.com, I expressly consent by my electronic signature to receive marketing communication, including telephone calls to any wireless number I have provided using an automated dialing system, and artificial or pre-recorded messages, emails and text messages (SMS) from insurance companies and brokers or their agents. I understand that I can opt out of these communications at any time by sending a written request to [email protected].


Collection and Use of Personal Information

  I agree that InsuranceTPA.com can process my TeleHealth enrollment and collect personal information from me including my identification information, health information required for TeleHealth or insurance enrollment, financial information required to establish payment for TeleHealth or insurance products that I select and website use information to provide relevant product information as described in the InsuranceTPA.com Privacy Policy InsuranceTPA.com Privacy Policy. Consistent with the InsuranceTPA.com Privacy Policy, I agree that InsuranceTPA.com can provide my personal information to affiliated third parties so I can receive information about other insurance products that might be useful to me. I understand that my personal information may be transferred or sold by an affiliated third party. I can opt out of the sale of my personal information by clicking on this button: