GoTo Telemed

55 W 14th St, Helena, MT 59601 | (660) 628-1660

Service Level Agreement

1 Review agreement

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2 Fill details & sign

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3 Payment link via email

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4 Signed PDF emailed

I am applying as a:

Signer Information

Complete the details below and sign. Your personalized state-specific payment link will then be emailed to you.

Full Legal Name *

Phone Number *

Email Address *

DBA / Practice Name *

Street Address *

City *

State *

ZIP Code *

Profession Title *

Licensed State(s) *

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0 selected

Tap every state where you hold an active license or compact privilege — selected states appear above as removable chips.

⚠ REQUIRED DISCLOSURES & CONSENT Read and tick each box below — signing is locked until all four are confirmed.

1Onboarding Stages & Refund Policy. I have read the 12 onboarding stages (Schedule 1) and understand every stage requires my active participation. A refund is available only where GoTo Telemed fails to deliver a stage within its control (Schedule 3); once credentialing submission or training access begins, the fee is otherwise non‑refundable. 2Payment Disputes & Chargebacks. I will raise any billing concern with GoTo Telemed first and allow ten (10) business days to resolve it before any external dispute, and I will never file impulsive or bad‑faith chargebacks — exercising my Fair Credit Billing Act and EFTA rights in good faith only (Schedule 4). 3Regulatory Compliance & Board Transparency. I will follow HIPAA / PHI protections, HHS OIG policies and FTC requirements. I consent that a copy of this signed Agreement — including my consent to its non‑refundable terms — may be shared with the licensing board(s) of my declared state(s), and I understand that HIPAA/PHI or OIG violations, bad‑faith disputes, defamation, or trade‑secret misuse may lead to civil action and board reporting (Schedules 5 & 7). 4Licensure Declaration. Select your profession title and licensed state(s) above — your personalized declaration will appear here before you confirm it.

0 of 4 confirmed

Digital Signature *

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⌨ Type Signature

Sign above the line

Use your mouse or finger to draw your signature above.

Your typed name will be applied as your legal electronic signature.

I agree that signing electronically is the legal equivalent of my handwritten signature, and I consent to the capture of my IP address, approximate location, and timestamp for verification purposes (ESIGN Act / UETA).

By signing, you acknowledge that you have read, understood, and agree to all terms of this Service Level Agreement.

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Agreement Signed Successfully

Thanks for signing the agreement! Check your email — your personalized, state‑specific payment link will be sent from our end; please complete it to finalize your agreement fees. Generating your unique SLA fees link may take 5 minutes up to 24 hours due to state regulations and privacy. A signed copy of your SLA is being emailed to you.

Complete Your Payment → Continue to Onboarding Portal →

Securing your agreement…

Encrypting your signature and preparing your invoice.

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Final Step — Acknowledge & Sign

Three quick confirmations before we secure your agreement.

Your 12 onboarding stages: Payment Confirmation → Self-Paced Training (15–20 day window you set) → Assessment Test → Self-Credentialing → EMR Signup → Hospital Enrollment → Malpractice Certificate → Business Email → Provider Business Webpage → Coordinator & Biller Allocation → Patient Portal Allocation → Patient Allocation. Stages unlock in sequence and every stage needs action from you. Track them at gototelemed.com/pst and raise any problem through the support ticket system in your portal first.

⚠ Please read carefully. Refunds are available only where GoTo Telemed fails to fulfill a stage within its control (Schedule 3). False or bad-faith chargebacks, HIPAA violations, misuse of patient medical records, upcoding or other fraudulent billing, and platform misconduct may be reported to state medical and dental boards, the HHS OIG, the Office for Civil Rights, CMS, and state Attorneys General — together with a copy of this signed SLA and your acknowledgement record (Schedule 5).

The 12 stages. I have read the 12 onboarding stages and the participation covenant (Schedules 1–2). Each stage requires my active participation, stages unlock in sequence, and I will use the support ticket system or the listed contacts to raise any problem first. Refunds & disputes. A refund is available only if GoTo Telemed fails to fulfill a stage within its control (Schedule 3). I agree not to file impulsive or bad-faith chargebacks, to contact GoTo Telemed first and allow ten (10) business days to resolve any concern (Schedule 4), and to complete the stages to receive the full value of my membership. Compliance & reporting. False chargebacks, HIPAA violations, misuse of patient records, fraudulent billing including upcoding, or any misconduct on the platform may be reported to the authorities listed in Schedule 5 together with this signed SLA and my acknowledgement record, and federal and state penalties apply to such conduct.