Boyle TelaMedPlus Opt In

Thank you for choosing the Standard Plus benefits from TelaMedPlus. Please fill out this short form then "submit" to be enrolled into the program. Your Standard Plus Card includes all these benefits:

Telamedicine Pharmacy MRI CT Scans Hearing Diabetic Supplies Wellness Online Medical Equipment Lab Work & Testing WorkLife Services

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Birth Date

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New Benefits (NB) is the benefits administrator. NB will bill Employer / Employee on the last business day of the month. Employer / Employee agrees to pay NB by the twentieth (20th) day of the subsequent month. If Employer / Employee fails to pay NB by the twentieth (20th) NB may notify Employer / Employee in writing of such failure to pay and issue a warning to Employer / Employee that if payment in full for all previously billed amounts is not received within five (5) days from date of notice, NB may elect, without notice, to cease providing Employer's / Employee's members access to the NB Membership Services pending receipt of payment.

Employer/Employee has the right to discontinue any above program at any time with thirty (30) days advance notice.

The undersigned Employee agrees to the conditions printed above and assumes no liability other than as specified.

I have read and accept.

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