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Instructions for Completing the TelaDoc Medical History Disclosure
Please complete the entire form using blue or black ink and print clearly. Any MHD that is incomplete or illegible will be considered unusable, and you will have to complete a new form.
NOTE: The fast and free way to complete your Medical History Disclosure is by logging on to your account and completing the MHD online. Simply click Login and use your username and password to access your account.
The following instructions are for completing the paper version of the MHD:
- Print your legal name (first and last).
- Identify the company/organization with whom you are affiliated.
- Provide your complete mailing address, city, state, and zip code.
- Check the appropriate box to identify whether this Medical History Disclosure is for the primary or a dependent member on the account.
- If the MHD is for a dependent member, please print the first and last name of the primary member on the account.
- Read each medical question in the following tables. Answer “yes” or “no” to each by clearly checking the appropriate box.
- Drug Allergies – clearly list any allergies to prescription or OTC drugs. If no allergies, then write “NONE.”
- List all medications currently being taken. Include OTC drugs and herbal supplements.
- Read the Terms and Conditions.
- Print your full name and enter the date of birth on the lines provided.
- Sign and date the form (required).
- Return the completed form to your employee benefits or HR office or by mail to:
- TelaDoc, Inc.
4100 Spring Valley
Suite 600
Dallas, TX 75244
You may also complete the MHD via telephone by calling 1-800-TelaDoc (1-800-835-2362).
Please note, there is a $12 charge for completing the MHD on the phone.
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