Opt Out of the Telehealth Program

Opt Out of the Telehealth Program

Village of Algonquin, Illinois
Use this form to opt out of the Village of Algonquin’s Telehealth Program and remove the $6.00 monthly fee from your utility bill. Once processed, your household will no longer have access to services provided by MD Health Pathways.

Please note: This form applies only to residential water and sewer utility customers located within the corporate boundaries of the Village of Algonquin.
Are you confirming that you would like to opt out of the Telehealth Program?*

Yes, I would like to opt out.
Name*

First NameLast Name
Service Address*

Street Address

Street Address Line 2

CityState

Postal Code
Please provide your water and sewer utility account number if available.
Your account number isn’t required, but it can help us verify your service address and locate your account more quickly. Refer to the example below if you need help finding it.
By checking the box below, I confirm that I am the authorized utility account holder and wish to opt out of the Village of Algonquin Telehealth Program. I understand this will remove the $6.00 monthly fee from my utility bill and end access to MD Health Pathways services for my household. I agree this form serves as my legal electronic signature and may be followed up with a traditional signature if needed.
Authorization Agreement*

I agree.
Please provide your email address to receive confirmation.
example@example.com
Has been contacted:
Should be Empty: