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Telemedicine of America Enrollment
  1. (*) Required fields. Have the PRIMARY member fill in this form. ALL information is strictly confidential and will not be shared.
  2. Your Enrollment will START on the FIRST DAY of the following month.
  3. Choose Your Broker(*)
    Invalid Input
  4. PRIMARY MEMBER INFORMATION
  5. First Name(*)
    Please type your first name.
  6. Last Name(*)
    Please type your last name.
  7. Gender(*)
    You must check on button
  8. Birthdate(*)
    Please enter in the format mm-dd-yyyy
  9. MailingAddress 1(*)
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  10. MailingAddress 2
    Invalid Input
  11. City(*)
    Invalid Input
  12. State(*)
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  13. Zip(*)
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  14. Home Phone(*)
    Please input your phone in the following format: 123-456-7890
  15. Cell Phone
    Please input your phone in the following format: 123-456-7890
  16. E-mail(*)
    If you do not have an email please sign up for a free email with one of the major services. We need to send confirmations and other information in email to you.
  17.  
  1. DEPENDENT INFORMATION (only complete if enrolling dependents who will also use this service.)
  2. Spouse First Name
    Please type your first name.
  3. Spouse Last Name
    Please type your last name.
  4. Spouse Gender
    You must check on button
  5. Spouse Birthdate
    Please enter in the format mm-dd-yyyy
  6. Dependent1 First Name
    Please type your first name.
  7. Dependent1 Last Name
    Please type your last name.
  8. Dependent1 Gender
    You must check on button
  9. Dependent1 Birthdate
    Please enter in the format mm-dd-yyyy
  10. Dependent2 First Name
    Please type your first name.
  11. Dependent2 Last Name
    Please type your last name.
  12. Dependent2 Gender
    You must check on button
  13. Dependent2 Birthdate
    Please enter in the format mm-dd-yyyy
  14. Dependent3 First Name
    Please type your first name.
  15. Dependent3 Last Name
    Please type your last name.
  16. Dependent3 Gender
    You must check on button
  17. Dependent3 Birthdate
    Please enter in the format mm-dd-yyyy
  18. Dependent4 First Name
    Please type your first name.
  19. Dependent4 Last Name
    Please type your last name.
  20. Dependent4 Gender
    You must check on button
  21. Dependent4 Birthdate
    Please enter in the format mm-dd-yyyy
  22. Dependent5 First Name
    Please type your first name.
  23. Dependent5 Last Name
    Please type your last name.
  24. Dependent5 Gender
    You must check on button
  25. Dependent5 Birthdate
    Please enter in the format mm-dd-yyyy
  26.  
  1. COVERAGE LEVEL
  2. Choose the plan and price.
  3. Your Plan(*)


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  4. Please type your credit or debit card information below:
  5. Type of Card(*)
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  6. Credit or Debit Card #(*)
    Format: 0000-0000-0000-0000
  7. Expiration Date(*)
    Enter the expiration date in the format MM/YYYY.
  8. Security Code(*)
    Enter the security code. It is the last three digits printed on the back of the card on the signature line.
  9. First Name on Card(*)
    Please type the first name as it appears on the credit card.
  10. Middle Name or Initial
    Please type your middle initial or name as it appears on the credit card.
  11. Last Name on Card(*)
    Please type the last name on the credit card.
  12. Billing Address Line1(*)
    Invalid Input. Please enter your credit card billing address.
  13. Billing Address Line2
    Invalid Input
  14. City(*)
    Invalid Input
  15. State(*)
    Invalid Input
  16. Zip(*)
    Invalid Input
  17.  
  1. Please indicate the best way to contact you.
  2. Contact to confirm your submission
  3. Confirmation
    Invalid Input
  4.   

Direct Enrollment Disclaimer:

Telemedicine of America operates within state regulations and may not be available in your state. State regulations prohibit service in AR, IA, OH, LA, OK and ID. State regulations may change and affect your service. 

After you enroll, an e-mail to setup your account will be sent. 
Please follow the instructions to setup your password and account. 
Once you login, please fill out your medical history and demographic information completely. 
You can schedule a consult at any time through your personal health portal. A Member Login ID will be provided upon enrollment.  

 

AFTER the first day of the following month, please allow up to 72 hours for your account to be active and login e-mail sent. e.g. If you sign up in January, your service will start after February 1st.

Telemedicine of America services are used to treat common conditions and episodic care.  We do not prescribe DEA controlled, mood altering drugs, lifestyle drugs or those that have the harm or potential of abuse. Telemedicine of America reserves the right to deny service to an individual. 

Contact us through our contact form provided in the contact us tab above.

Please do not provide any medical information when writing our offices.

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