USC - PurpleCARE myvirtualdoctor Opt-Out Form

Virtual Health Care is always available! myvirtualdoctor is your virtual health care service providing eligible students unlimited 24/7 access to licensed health experts, including nurse practitioners and doctors.

myvirtualdoctor Opt-Out Application

Fall 2023 deadline to submit applications
Monday, September 23^rd, 2024, 11:30 PM

Students can opt-out of myvirtualdoctor based on their personal choice by the applicable deadline. Once you opt-out you will not be able to re-enroll in the program until your enrollment anniversary.

Important notes:

The student is given one (1) opportunity to opt-out of myvirtualdoctor each year. The student is only able to opt-out during their initial opt-out period or the opt-out period that corresponds with their enrolment anniversary.
Approval of the Student’s opt-out will result in the myvirtualdoctor fee being credited/or refunded according to the school's policy.
The myvirtualdoctor opt-out is an annual opt-out. You will be re-enrolled next year on your enrolment anniversary and if you wish to opt-out again you will need to complete a new online form prior to the applicable deadline.
NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan's mandatory fees, should they miss the applicable opt-out deadline.
Once you complete the opt-out form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting an opt-out request.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: healthdental@westernusc.ca

myvirtualdoctor Opt-Out Form

Students must use their Western Provided Student ID number. Your student ID can be located in your student centre account or your Western One Card.

Please complete all information on the myvirtualdoctor opt out form and we will process your application as soon as we can.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Transit # must be at least 5 digits long * Required

Institution #

Institution # must be at least 3 digits long * Required

Account #

Account # must be numeric * Required

USC Benefits Plan Office

Email: healthdental@westernusc.ca
Address: University Community Centre
Room #320
1151 Richmond St
London, Ontario N6A 2K5

General Inquiries Line

Monday to Friday from 8:00am to 7:00pm EST

Phone: 1-877-746-5566 Ext. 7249

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