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Tele Medicine Service Enrollment

UNLIMITED CALLS / CONSULTATIONS | NO PER CALL / CONSULTATION FEE | AVAILABLE 24/7/365

INCLUDES MEMBER AND ALL HOUSEHOLD DEPENDENTS

Product Cost*
- MONTHLY PLAN FOR $5.00 PER MONTH
- YEARLY PLAN FOR $50.00 PER YEAR (SAVE $10)
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PAYMENT INFORMATION:*

American Express
Discover
MasterCard
Visa
CARD NUMBER EXPIRATION DATE SECURITY CODE CARDHOLDER NAME
CARD BILLING ADDRESS:*
STREET ADDRESS CITY STATE ZIP CODE
MEMBER NAME:*
FIRST LAST
MAILING ADDRESS*
PLEASE JUST USE MY BILLING ADDRESS

STREET ADDRESS CITY STATE ZIP CODE

WE WILL MAIL YOUR MEMBER ID CARD TO THIS ADDRESS
BIRTH DATE*
GENDER
PROMOTION CODE
EMAIL ADDRESS / USER NAME:*
** YOUR EMAIL ADDRESS WILL BE USED AS YOUR ACCOUT USER NAME.
PERSONAL PASSWORD:*
ENTER PASSWORD CONFIRM PASSWORD
TERMS AND CONDITIONS*
- I HEREBY AUTHORIZE SOCIALLITY TO CHARGE MY CREDIT CARD OR DEBIT CARD THE AMOUNT DUE FOR THIS PROGRAM ACCESS ACTIVATION.
- I HEREBY AUTHORIZE SOCIALLITY TO AUTOMATICALLY CHARGE MY CREDIT CARD OR DEBIT CARD THE MONTHLY OR YEARLY ACCESS FEE. I UNDERSTAND THAT THIS CHARGE WILL AUTOMATICALLY BE MADE UNTIL SUCH A TIME THAT I ELECT TO CANCEL MY ACCESS.
- I HEREBY ACKNOWLEDGE AND UNDERSTAND THAT I MAY CANCEL THE PROGRAM ACCESS AT ANY TIME WITHOUT PENALTY. UPON CANCELING MY ACCESS, SOCIALLITY WILL IMMEDIATELY DISCONTINUE CHARGING THE MONTHLY OR YEARLY ACCESS FEE.
- I HEREBY ACKNOWLEDGE, AGREE TO, AND ACCEPT THE SOCIALLITY PRIVACY POLICY, THE SOCIALLITY WEBSITE USE TERMS AND CONDITIONS, THE SOCIALLITY ACCESSNOW TERMS AND CONDITIONS, AND THE SOCIALLITY HEALTHCARE COIN TERMS AND CONDITIONS.
- I HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT NONE OF THE PROGRAMS OR SERVICES ARE AVAILABLE TO ME BY SOCIALLITY ARE INSURANCE PRODUCTS. THE SOCIALLITY ACCESSNOW PROGRAM IS DESIGNED TO HELP MANAGE OUT-OF-POCKET AND SELF-PAY DEDUCTIBLE EXPENSES ARE ARE IN NO WAY TO BE CONSIDERED INSURANCE.