Benefit Boost Cancellation Request Form

Member Cancellation Request Form

For cancellations of Benefit Boost Subscription membership products.
Today's date*

MonthDayYear
Original Date of Purchase*

MonthDayYear
Request of Cancellation*

Cancellation for future drafts onlyCancellation and Refund (first 30 days)
Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Benefit Boost Subscription Products to Cancel (select all that apply)

MeMD Virtual VisitsVirtual PCP Solution with MeMDParamount RX Prescription DiscountsSML Dental DiscountsBenefit Boost (comprehensive subscription product)
Reason for Cancellation and Comments*
Refund Policy: If you are not completely satisfied with your Benefit Boost Subscription Membership Product, please call your Personal Member Concierge at 866-438-4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisfied with your Benefit Boost Subscription benefits and services. Please be aware that premium & dues can’t be refunded if a claim was filed.

Note: This non-insurance membership is separate from any other insurance or supplemental products you have purchased. Please contact your agent for any products other than the a la carte health and wellness non-insurance Benefit Boost Subscription Products.

If you are canceling, please make sure to cancel using the member cancellation phone number at 866.438.4274 or this cancellation form located at benefitboost.com/billing.html. Please do not cancel through your agent. Cancel directly with your Personal Member Concierge to make sure your cancellation request is handled promptly and correctly.
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Member Cancellation Request Form