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myvirtualdoctor Opt-out Form Terms and Conditions

Submission of an online form indicates:

- an understanding that it is solely the responsibility of the student whose name and identification number (The Student) is on the form to ensure that the form has been received by the benefit office/representative;

- an understanding that the information provided is required in order fulfill the purpose of the form;

- authorization and consent to the use, release and exchange of said information between the educational institution, the student organization, the plan broker, third party service providers and the insurance company(s) to be used solely in connection with the administration of the Student Benefits Plan;

- confirmation that all the information provided is accurate; and

- that additional terms as indicated below by type of form also apply.

Falsification of any information provided by The Student is considered to be a serious form of fraud.

OPT-OUT FORM: The Student wishes to decline the myvirtualdoctor coverage. The Student understands that they would have been able to use this program to access virtual primary care services, including appointments with primary practitioners, prescription delivery service, and access for eligible dependents. The Student acknowledges that as a result of the opt-out, they forfeit all rights to coverage otherwise available to them under the myvirtualdoctor program. The Student realizes that they will not be able to rejoin the program until their next enrolment anniversary, or within the deadline provided should the student lose access to their primary care physician.

OPT-OUT DEADLINE: The opt-out deadline dates are established by the Institution or Student Organization. You will not be able to opt-out of coverage at any other point during the school year. The deadline is October 3 for September starting students, and for all other students 30 days from the start date of your classes when you are first eligible for the plans or on your enrolment anniversary. For example, if your program starts November 1, you must opt-out prior to the end of day November 30. NO EXCEPTIONS will be made if the deadline is missed. It is The Student's responsibility to pay the program fees, should they miss the applicable opt-out deadline.

OPT-OUT DURATION: An approved opt-out applies to the coverage year in which it is submitted. The student needs to submit an opt-out on each subsequent enrolment anniversaries if the student wishes to continue to be opted-out of the myvirtualdoctor program

OPT-OUT EMAIL CONFIRMATION: You will receive a reply email confirmation after you complete and submit the online opt-out. Please retain a copy of the email confirmation for your records. The email confirmation is your ONLY proof that you applied to opt-out of the coverage.