Virtual E-Sign Payroll Deduction Authorization Form

I hereby authorize payment to be deducted from my paycheck in the amount described above as may now or hereafter be payable by me under the plan purchased through AllyHealth. In the event of a rate change, I authorize a corresponding change in my payroll deduction (as long as said change is communicated to me at least 30 days prior to implementation). I hereby accept the terms and conditions of service for AllyHealth, including but not limited to the following statements: AllyHealth membership is not insurance nor is it designed to replace health insurance. Access to physicians provided through AllyHealth is intended to supplement, not replace, the “in person care” provided by a primary care physician. Additional Terms and Conditions of Service are available for download and print from http://www.allyhealth.net/terms-and-conditions/