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Group Formation Document
The following document concerns the organization of the group United Benefits, General Partnership (“GP”) to which I am joining under the following conditions. All other group partners must join under the same conditions.
As enrolled, I hereby agree to the terms and conditions of this document and endorse the creation/maintenance of this group partnership.
I acknowledge and understand that I am voluntarily becoming a member and that this agreement is non-transferable.
I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance.
I acknowledge and understand that I am responsible for any charges incurred for health care services performed including but not limited to emergency room, hospital and specialty services.
I acknowledge and understand that MyFit Marketing must maintain a record of my information and must protect the privacy of my information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available for my review at any time at WWW.MyfitPrivacy.com or upon request.
I acknowledge and understand that no child over 26 can be on my health plan and that he/she must enroll in their own plan or loose health benefits.
I acknowledge and agree to pre-pay my monthly health plan and associated fees on or before its due date for the upcoming month. If I am unable to pay my fee(s) on time, I understand that I will be charged a $25 late fee initially and $25 per month thereafter and agree to owe the total late fee balance along with all past due monthly care fees and acknowledge that my service agreement may be terminated.
I acknowledge and understand that I may terminate this Agreement at any time and for any or for no reason by providing written notice to MyFit Marketing. Monthly fees will continue to accrue until written termination notice is received. Any pre-paid monthly fees will be returned when Myfit Marketing has received the written termination and will be refunded within forty-five (45) days. Refunds are only given if cancellation request was received before the 1st of the requested canceled month.
In addition, I acknowledge and understand that MyFit Marketing may terminate this Agreement by providing me written notice and any pre-paid monthly fees will be refunded to me within ten (10) business days.
I acknowledge and understand that Myfit Marketing may add or discontinue services or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least 60 days’ notice of such fee schedule changes.
I acknowledge and understand that MyFit Marketing is not insurance and does not provide payment and or reimbursement to me or on behalf of me to any charges occurred while on this plan. This plans sole purpose is to provide me access to affordable healthcare that has wellness benefits, and other discounted medical benefits and self-pay tools.
Statement of Understanding
MyFit Marketing provides lifestyle-related benefits and services to its members. Participation in Plan is required in order to be eligible to purchase insurance coverage. By Applying for a MyFit Marketing plan, you are requesting enrollment in a bundled plan. You understand that the bundled plan you chose to participate in includes sponsored health program by United Benefits that you agree to join as a general partner, and that additional marketing and benefits cost will be deducted along with your health plan premiums. You also understand that your failure to remit payment for plan will result in loss of eligibility to participate in all sponsored programs and benefits.
Rights and Responsibilities
In the event of plan termination, I understand that I must complete a written Service Cancellation Form. Any differences in payment between my billing date and the date of cancellation will be refunded to me via the payment method I have chosen for my monthly fee.
I understand that if my account is overdue, I am responsible for resolving the outstanding balance prior to my service cancellation.
I understand that I have the right to considerate, respectful, and nondiscriminatory communication from MyFit Marketing. I also understand that I am responsible for communicating clearly and respectfully with MyFit Marketing staff members. Should I become dissatisfied with MyFit Marketing’s services, I agree to notify MyFit Marketing immediately, so my concerns may be addressed in a timely manner.
I am responsible for making prepaid monthly payments on time. On time means on or before the 15th of the month prior to coverage.
I am responsible for my own healthcare decisions and expenses.
I authorize Health Plan, a third-party biller, to auto deduct monthly for my plan services until MyFit Marketing has received written notification of cancelation. I also understand that I am fully responsible for any charges from my bank for these transactions.
|Standard||1-5 business days||$7.95|
|Two Day||2 business days||$15|
|Next Day||1 business day||$30|
|* Free on orders of $50 or more|