Insurance Telehealth Application

INSURANCE TELEHEALTH APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth: Phone: Email:

Policy Details

Policy Type: Individual Family Employer Group

Coverage Options (select all that apply)

Video consultations (real-time audiovisual)
Audio-only consultations
Store-and-forward / asynchronous messaging
Behavioral health / therapy
Remote chronic condition monitoring
Electronic prescribing
Specialist referral coordination
Limited to in-network providers

Exclusions and Limitations

The following services and circumstances are expressly excluded from telehealth coverage unless specifically endorsed: emergency medical stabilization, services requiring hands-on procedures, injuries arising from acts of war or criminal activity, and claims resulting from materially false statements by the applicant. Any service performed outside the policy territory or by a provider not credentialed under this policy is excluded.

Beneficiary Designation

Beneficiary Name:

Consent, Authorization and Acknowledgments

By selecting the following acknowledgments and signing below, the applicant certifies acceptance of telehealth delivery methods, understands the limitations of remote care, and authorizes necessary actions identified in each clause.

I consent to receiving healthcare services via telehealth modalities described in this application.
I authorize release of my medical records and relevant information to telehealth providers, insurers, and third-party administrators for claims processing, care coordination, and quality assurance.
I agree to electronic delivery of notices, explanations of benefits, invoices, and communications related to telehealth services and billing.
I acknowledge that certain conditions may require in-person evaluation and that telehealth may be inappropriate for emergency situations; I will seek emergency care when necessary.
I authorize assignment of benefits to providers for covered telehealth services and permit direct billing to the insurer as applicable.

Declaration and Certification

I certify under penalty of law that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission, or fraudulent statement in this application may result in denial of coverage, rescission of benefits, or criminal and civil penalties as permitted by law. I authorize the insurer and its authorized representatives to verify any information provided, including medical records, billing history, and other eligibility or underwriting data.

I agree to comply with the insurer's telehealth policies, payment terms, and notification procedures. I accept that coverage limits, co-payments, deductibles, and preauthorization requirements specified by the insurer will apply to telehealth services unless otherwise stated in an endorsement. I shall indemnify and hold harmless the insurer and its affiliates for actions arising from reliance on the information I have supplied, except to the extent of coverage provided under the policy.

Certification of Accuracy

I certify that I am authorized to apply for the coverage described herein. I understand that coverage will be effective only upon acceptance by the insurer and issuance of policy documentation. I agree that any electronically captured signature shall have the same force and effect as an original signature.

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