Restore Telehealth Services Enrollment

Restore Telehealth Services Enrollment

Village of Algonquin, Illinois
Use this form to restore your household’s enrollment in the Village of Algonquin’s Telehealth Program. Residents are automatically enrolled in this program; however, if you previously opted out, submitting this form will reinstate your participation. Once processed, your household will regain access to TAP Telehealth services, and the $6.00 monthly fee will resume on your utility bill. Enrolled residents may text licensed Illinois physicians for everyday medical questions, prescription requests, and basic work or school notes through 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 restore your enrollment in the Telehealth Program?*

Yes, I would like to restore my enrollment.
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 restore my household’s enrollment in the Village of Algonquin Telehealth Program. I understand this will reinstate the $6.00 monthly fee on my utility bill and restore access to MD Health Pathways services for my household. I agree that 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: