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NTC-TeleHealth Enrollment Form

Member Information

First Name *

Middle Name *

Last Name *

Sex *

Birth Date (00/00/0000) *

Total Fee for Member and 5 dependents=$85.00/annually *

Reference Code (Enter 01 if unknown) *

Household / Adult Primary Contact

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Alternate Phone

Email Address *

Billing Information

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV/CVC code (normally on back of card) *

Terms and Conditions

*

NTC-TeleHealth Terms & Conditions NTC-TeleHealth+ CUSTOMER SERVICE AGREEMENT Terms and Conditions NTC-TELEHEALTH is not health insurance and does not replace your primary care physician, but is a resource designed to improve wellness and lifestyle. If you have an urgent medical condition, please dial 911. All services HIPAA compliant. 1. SERVICES. During the Term (as defined below) and on a non-exclusive basis, NTC will provide Customer with the NTC telemedicine services and RFL telephonic counseling, patient advocacy and concierge services set forth on the attached Schedule 1 (“Services”) for use by Customer, including Customer’s legal dependents. 2. DUTIES OF THE PARTIES. o A. Duties of NTC. NTC shall (i) deliver and support the Services; (ii) manage and securely maintain a database of profile information provided by Customer; and (iii) provide Customer with utilization reports upon request. NTC may discontinue any Service without liability at any time; provided, however, NTC will use reasonable efforts to notify Customer in advance of any such discontinuation. o B. Duties of Customer. Customer shall (i) submit to Company or its designated Third Party Administrator (“TPA”) enrollment information; and (ii) timely make all payments to Company. 3. PRICING AND PAYMENT. Customer shall pay Company or its designated TPA (i) a monthly fee (“Fee”) for use of Company’s services. Any payment not received by Company or its designated TPA on or before the due date shall result in suspension of the Services. Company reserves the right to change the Fee and other fee pricing for any future Effective Period upon providing written notice to Customer at least sixty (60) days prior to the expiration of the then-current Effective Period. All amounts shall be payable by Customer to Company or its designated TPA without right of setoff, deduction or demand. 4. TERM AND TERMINATION. Unless otherwise set forth, this Agreement shall be effective until the one month anniversary of the Effective Date of this Agreement, and shall automatically renew for additional one-month periods on each anniversary of the Effective Date. Each one-month period of this Agreement is referred to as an “Effective Period” and collectively all of the Effective Periods of this Agreement are referred to as the “Term.” Either party may terminate this Agreement at any time by providing the other party at least thirty (30) days prior written notice. Company may immediately terminate this Agreement upon written notice to Customer if Customer fails to make any payment to Company or its designated TPA when due. 5. OWNERSHIP. All materials, including all copyrights, trademarks, logos and other identifying marks (collectively “Materials”) shall remain the exclusive property of Company. All Materials are proprietary and may not be reproduced, duplicated or disseminated for any purpose. NTC.com, ConsultADoctor.com, MyLIfeValues.com and any other Web site(s) made available by Company for promotion and/or use of the Services (collectively, the “Website”), are and shall remain the exclusive property of Company, NTC, and RFL. 6. REPRESENTATIONS AND WARRANTIES. o A. Company represents and warrants to Customer that Company, NTC, and RFL will abide by and comply with the Health Insurance Portability and Accountability Act of 1996 with respect to any personal medical information provided to Company, NTC, or RFL by Customer. o B. Customer acknowledges, understands, and agrees that (i) the physicians, consultants and others providing services in connection with the Services will not treat severe and/or emergency conditions as part of the Services and may recommend that Customer visit his/her primary care physicians, specialists or local facility if deemed appropriate, in the sole and absolute discretion of such; and (ii) when Customer provides prior written permission, physicians providing services in connection with the Services will facilitate continuity of care. o C. Each party represents and warrants to the other party that (i) it has the full right, power, and authority to enter into and to perform this Agreement; and (ii) this Agreement constitutes a valid and binding obligation of such party, enforceable against it in accordance with its terms, subject to applicable bankruptcy, insolvency, reorganization, moratorium, and other laws affecting the rights of creditors generally. o D. DISCLAIMER OF WARRANTIES. COMPANY DOES NOT WARRANT THE UNINTERRUPTED OR ERROR-FREE OPERATION OR PROVISION OF THE SERVICES. ALL INFORMATION, MATERIALS, AND SERVICES ARE PROVIDED TO CUSTOMER “AS IS.” EXCEPT AS SPECIFICALLY SET FORTH IN THIS AGREEMENT, COMPANY HEREBY DISCLAIMS ALL REPRESENTATIONS AND WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON-INFRINGEMENT. COMPANY MAKES NO REPRESENTATIONS OR WARRANTIES WITH RESPECT TO THE SATISFACTION OF GOVERNMENT REGULATIONS REQUIRING DISCLOSURE OF INFORMATION ON PRESCRIPTION DRUG PRODUCTS, OR ANY TREATMENT, ACTION OR APPLICATION OR PREPARATION OF MEDICATION BASED ON INFORMATION OFFERED OR PROVIDED THROUGH THE SERVICES. 7. LIMITATION OF LIABILITY. NEITHER PARTY WILL BE LIABLE TO THE OTHER PARTY OR ANY THIRD PARTY FOR ANY OF THE FOLLOWING ARISING OUT OF THIS AGREEMENT AND/OR THE SERVICES: ANY SPECIAL, INDIRECT, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES, WHETHER BASED UPON BREACH OF WARRANTY, BREACH OF CONTRACT, NEGLIGENCE, STRICT TORT OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. CUSTOMER ACKNOWLEDGES AND AGREES THAT COMPANY’S AGGREGATE LIABILITY TO CUSTOMER FOR ANY DAMAGES, LOSSES, FEES, CHARGES, EXPENSES AND/OR LIABILITIES ARISING OUT OF OR IN CONNECTION WITH THIS AGREEMENT AND/OR THE SERVICES SHALL NOT EXCEED THE FEES PAID BY CUSTOMER PURSUANT TO THIS AGREEMENT FOR THE ONE (1) MONTH PERIOD PRIOR TO THE FIRST OCCURRENCE OF THE APPLICABLE DAMAGES, LOSSES, FEES, CHARGES, EXPENSES, AND/OR LIABILITIES. 8. INDEMNIFICATION. Each party (each, the “Indemnifying Party”) agrees to defend, indemnify and hold harmless the other party and the other party’s owners, officers, directors, employees, contractors, representatives, agents, and affiliated entities (collectively, the “Indemnified Parties”) from and against any third party claims (each, a “Claim”) arising out of or in connection with any breach of this Agreement by the Indemnified Party including, without limitation, a breach of any representation, warranty, covenant, or obligation under this Agreement. The Indemnified Party shall promptly notify the Indemnifying Party in writing of any Claim and shall reasonably cooperate with the Indemnifying Party in the defense of such Claim. 9. GENERAL TERMS. This Agreement is the entire agreement between Company and Customer and supersedes any prior understandings or written or oral agreements between Company and Customer with respect to the subject matter of this Agreement. No waiver of a breach of any provision of this Agreement by any party shall be construed as a waiver of a subsequent breach of the same or any other provision of this Agreement. Customer’s obligation to pay for any Services received by Company, NTC, or RFL and each of the provisions of Sections 5 through 12 shall survive the expiration or earlier termination of this Agreement. The invalidity of any provision of this Agreement shall not affect the enforceability of the remaining Agreement or any other provision of the Agreement. All exhibits and schedules to this Agreement are true, correct, and are hereby incorporated into by reference and made a part of this Agreement. This Agreement shall be binding upon, inure to the benefit of, and be enforceable by Company and Customer and their successors and assigns. This Agreement shall not be construed to give any person other than Company and the Customer any legal or equitable right, remedy or claim under or with respect to this Agreement. This Agreement may only be amended or changed pursuant to a written document duly executed by both Company and Customer. This Agreement will not create a joint venture, partnership or other formal business relationship or entity of any kind, or an obligation to form any such relationship or entity. Each party will act as an independent entity and not as an agent of the other party for any purpose, and neither will have the authority to bind the other. 10. NOTICES. All notices and other communications required pursuant to this Agreement shall be written and shall be delivered by one or more of the following methods: (a) USPS First Class Mail addressed to the parties at the addresses set forth above; (b) nationally recognized overnight delivery service (such as FedEx, UPS, DHL or USPS Express Mail) addressed to the parties at the addresses set forth above; or (c) electronic mail to the parties at the electronic addresses set forth above. Parties may designate alternate addresses in writing. Each such notice shall be deemed delivered (i) in the case of delivery by USPS First Class Mail or overnight delivery service, on the date delivered or the date delivery is refused by the recipient; and (b) in the case of electronic mail, on the date sent the electronic mail is sent to the recipient. 11. DISPUTE RESOLUTION. Except as otherwise specifically set forth in this Agreement, the parties hereby agree to resolve any and all controversies, claims and/or disputes arising out of this Agreement (each, a “Dispute”) solely pursuant to the terms of this Section. o A. Management Resolution. All Disputes shall first be referred to the parties’ authorized representatives for discussion and resolution of the Dispute (“Management Resolution”), which representatives are the individuals who have executed this Agreement on behalf of their party. o B. Arbitration. If Management Resolution fails to resolve the Dispute, then the Dispute shall be resolved by final, binding arbitration (“Arbitration”) administered by the American Arbitration Association (“AAA”) under the AAA’s Commercial Arbitration Rules. In the event of any Arbitration, action to compel Arbitration, action to enforce an Arbitration award or action to seek injunctive relief pursuant to this Agreement, the prevailing party in such proceeding shall be entitled to an award of their reasonable attorneys’ fees and costs for each such proceeding, including the Arbitration, trial and for all levels of appeal. o C. Governing Law; Venue; Jurisdiction. This Agreement shall be governed by, and construed in accordance with, the laws of the State of Michigan (without giving effect to principles of conflicts of laws). For any action to compel Arbitration, enforce an Arbitration award or seek injunctive relief pursuant to this Agreement, the parties hereby expressly consent to the (i) venue of Oakland County, Michigan, USA, and each party hereby expressly waives any objection to such venue based upon forum non-conveniens or otherwise; and (ii) jurisdiction of the state and/or federal courts in and/or for Oakland County, Michigan, USA. o D. Injunctive Relief; Cumulative Remedies. Each party acknowledges and agrees that a violation or breach of any of the ownership or non-disclosure provision of this Agreement could cause irreparable harm to the non-breaching party for which monetary damages may be difficult to ascertain or an inadequate remedy. Therefore, each party will have the right, in addition to its other rights and remedies, to seek and obtain injunctive relief for any violation of the ownership or non-disclosure provisions of this Agreement, and each party hereby expressly waives any objection, in any such equitable action, that the other party may have an adequate remedy at law. The rights and remedies set forth in this Agreement are cumulative and concurrent and may be pursued separately, successively or together. SCHEDULE 1 DESCRIPTION OF SERVICES NTC-TELEHEALTH 1. NTC provides an exclusive bundled service comprised of three leading services, Teledoc, Inc., CONSULT A DOCTOR, AETNA RESOURCES FOR LIVING and WELLCARD HEALTH. 2. Fulfillment: NTC or its designated TPA will provide the following. o 1. A welcome email sent to the email address provided outlining the steps to activate the Customer’s account and access services. o 2. Membership Card with integrated Color tri-fold brochure mailed to address specified by Customer. o 3. Toll-free numbers and website login information. NTC-TeleHealth 1. NTC provides a network of licensed physicians and specialists accessible via telephone or secure email. 2. Coverage for Members, including legal dependents. 3. Membership Cards with unique Members identification number for each Member. 4. Physician Consultations – Available 24 hours per day, 7 days per week, and 365 days per year. o a. BY PHONE Customers access to a special toll-free number. 1. i. On Call: ask medical questions, NO medication can be ordered. 2. ii. Priority: Usually within 1 hour, guaranteed within 3 hours. Requires receipt of a completed Medical Assessment and History Questionnaire to create a physician/patient relationship and for medication to be ordered. 3. iii. By Appointment: available by next day. Requires receipt of a completed Medical Assessment and History Questionnaire to create a physician/patient relationship and ordering medications. o b. ONLINE 1. i. E-Consult: Secure email consultation with a physician through our secure messaging system. Ask medical questions. NO medication can be ordered. 5. Prescription Program – Only Customers who have accurately and fully completed the Medical Assessment and History Questionnaire and established a physician/patient relationship are eligible to receive medications. NO controlled medications are available through NTC. 6. Member Services Toll Free Support: Customers have access to Customer only toll-free support, 24/7. 7. Member Health Portal/ My Personal Health Manager (MyPHM) o a. My Health Library – Access medical library containing thousands of health topics from trusted sources. o b. My Symptom Checker – Interactive tool shows possible conditions based on Customers’ symptoms. o c. My Health Records (MyPHR) – Customers will have ability to store and update medical records. o d. Health Risk Assessment Tools – Empower Customers to review lifestyle factors and health risks. o e. My Message Center – Secure email medical consultations. o f. My Consult Center – Order a consult by appointment and other services and products. 8. Physician Response Times: o a. Tele-Consult On-Call – Within approximately 5 minutes. o b. Tele-Consult By Appointment – Within approximately 24 hours. o c. Tele-Consult Priority – Within approximately 1 hour, but no later than within 3 hours. o d. E-Consult – Within approximately 2 to 3 hours. 9. System Availability – Commercially reasonable efforts to make the Services available in full at all times. AETNA RESOURCES FOR LIVING 1. RFL helps its members handle life’s challenges. Our telephone counseling provides immediate, customized help. With RFL’s telephone counseling: o a. Customers can speak with a counselor any time — 365 days per year — from the comfort and privacy of home or anywhere else they choose. o b. From the moment they call, members engage instantly with a clinician — with no limit on the time it takes to help resolve their issues. 2. Aetna RFL also provides you with customized services to support all facets of Customers’ lives: o a. Legal/Financial: convenient access to qualified legal and financial professionals who can help resolve issues and concerns that may arise. 30 minutes free per issue, unlimited issues, 25% discounted rate thereafter. o b. ID Theft: RFL’s prevention tools can help Customers protect themselves and their families. In the unfortunate case of identity theft, the RFL Fraud Resolution team immediately responds, coaching Customers through the process to repair their identity and credit. o c. Patient Advocacy: RFL provides members with a Patient Advocacy program to help mediate remaining medical bills. A personal negotiator will act on Customers’ behalves, mediating solutions for remaining bills with medical facilities. Solutions could include: 1. Applying for financial assistance 2. Negotiating a settlement 3. Arranging a payment plan o d. Personalized assistance with child care, elder care, pet care and everyday needs. o e. Coaching or counseling to help Customers achieve work life balance. o f. Access to the online Discount Center, your one stop resource for every day savings on electronics, travel, movie tickets and more. o g. For a complete list of benefits, visit www.mylifevalues.com 3. The benefits of Resources For Living include: o a. Unlimited telephonic consultation o b. Easy, 24/7 access to clinicians o c. Personalized attention to Customers’ needs o d. The ability to communicate in multiple languages o e. Access to website resources 4. Access to RFL is received by members using the following methods: o a. By Phone: 1-877-856-1788 o b. By Website: www.mylifevalues.com 5. Aetna Resources for LivingSM is the brand name used for products and services offered through the Aetna group of subsidiary companies. The EAP is administered by Aetna Behavioral Health, LLC and Aetna Life Insurance Company (Aetna). 6. All calls are confidential, except as required by law (i.e., when a person’s emotional condition is a threat to himself/herself or others, or there is suspected abuse of a minor child, and in some areas, spousal or elder abuse). 7. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. I authorize the sales organization to charge me for the above total. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept the sales organizations terms and conditions as published on their website. By checking the box, I acknowledge that I have read, understand, and agree to the authorization

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