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Tele Medicine Service Enrollment

FULL YEAR OF SERVICE | UNLIMITED USAGE | INCLUDES MEMBER AND ALL HOUSEHOLD DEPENDENTS

Yearly Subscription Fee: $50.00

Product Cost
YOUR HOME STATE:*
Due to State regulations, the MDLive Tele Medicine Service is available only via telephone in your State. You will not be able to use the video conference feature.

Complete the enrollment process to start your Tele Medicine service subscription.
Due to State regulations, the MDLive Tele Medicine Service is available only via video conference in your State. You will not be able to with a MDLive doctor via telephone and must use the video conference feature for consultations.

Complete the enrollment process to start your Tele Medicine service subscription.
Great News. Your Home State does not have any restrictions on the use the Tele Medicine or Tele Health services. You will have access to physicians both via Telephone and via Video Conference.

Complete the enrollment process to start your Tele Medicine service subscription.
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 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 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.