careteam.springhealth.com
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104.16.51.111
Public Scan
Submitted URL: https://links.springhealth.com/u/click?_t=accc26ce9d6f4136bb2575ae7b5f7f35&_m=fbff416935e54d9f84a26ab76d2158a7&_e=rh4Q2...
Effective URL: https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=14448838263956
Submission: On May 10 via api from US — Scanned from DE
Effective URL: https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=14448838263956
Submission: On May 10 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /hc/en-us/requests
<form id="new_request" class="request-form" data-form="" data-form-type="request" action="/hc/en-us/requests" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="✓" autocomplete="off">
<div class="form-field select optional request_ticket_form_id"><label for="request_issue_type_select">Please choose a request type below</label>
<a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_gdskw68se" aria-label="Please choose a request type below" style="max-width: 100%;">Member Support Form</a><select name="request[ticket_form_id]"
id="request_issue_type_select" aria-label="Please choose a request type below" autofocus="autofocus" style="display: none;">
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new" value="-">-</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=360000123151" value="360000123151">Default Ticket Form</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=8933446650004" value="8933446650004">Appointment Cancellation/Reschedule Form (Providers & Members)</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=10330188302484" value="10330188302484">Inbound Referral</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=13075656435220" value="13075656435220">Appointment Cancellation/Reschedule Form (Coaching)</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=14448838263956" selected="selected" value="14448838263956">Member Support Form</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=15495106468116" value="15495106468116">Critical Incident Response Intake Form </option>
</select>
</div>
<div class="form-field string required request_anonymous_requester_email"><label for="request_anonymous_requester_email">Please enter the email address associated with your Spring Health account</label>
<input type="text" name="request[anonymous_requester_email]" id="request_anonymous_requester_email" aria-required="true">
<p>if you do not have a Spring Health account, please enter the email address associated with your benefit</p>
</div>
<div class="form-field string required request_subject" style="display: none;">
<label id="request_subject_label" for="request_subject">Add your desired Subject text for the specific form here</label>
<input type="text" name="request[subject]" id="request_subject" maxlength="150" size="150" aria-required="true" aria-labelledby="request_subject_label">
</div>
<div class="suggestion-list" data-hc-class="searchbox" data-hc-suggestion-list="true"></div>
<div class="form-field string required request_custom_fields_14922672270484">
<label id="request_custom_fields_14922672270484_label" for="request_custom_fields_14922672270484">What can we help you with?</label>
<input type="hidden" name="request[custom_fields][14922672270484]" id="request_custom_fields_14922672270484" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Account sign-up","value":"mef_account_creation"},{"label":"Benefits/Billing","value":"mef_billing"},{"label":"Medications","value":"mef_medication_refill_request"},{"label":"Paperwork requests","value":"mef_documents"},{"label":"Scheduling","value":"mef_scheduling"},{"label":"Technical issues","value":"mef_technical_issues"},{"label":"Other","value":"mef_nota"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922672270484_label"
value=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_99fqfwnv0" aria-required="true" aria-labelledby="request_custom_fields_14922672270484_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922637122068 optional" hidden="">
<label id="request_custom_fields_14922637122068_label" for="request_custom_fields_14922637122068">Are you a Customer or Employer?</label>
<input type="hidden" name="request[custom_fields][14922637122068]" id="request_custom_fields_14922637122068" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Customer","value":"mef_customer"},{"label":"Member","value":"mef_member"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922637122068_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_apntfdw8r" aria-required="true" aria-labelledby="request_custom_fields_14922637122068_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922652651924 optional" hidden="">
<label id="request_custom_fields_14922652651924_label" for="request_custom_fields_14922652651924">Is your insurance on file?</label>
<input type="hidden" name="request[custom_fields][14922652651924]" id="request_custom_fields_14922652651924" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Yes","value":"mef_insurance_on_file"},{"label":"No","value":"mef_no_insurance_on_file"}]"
aria-required="true" aria-describedby="request_custom_fields_14922652651924_hint" aria-labelledby="request_custom_fields_14922652651924_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_im8t81eok" aria-required="true" aria-labelledby="request_custom_fields_14922652651924_label" aria-describedby="request_custom_fields_14922652651924_hint" style="max-width: 100%;">-</a>
<p id="request_custom_fields_14922652651924_hint"> If not, please attach a picture on this form</p>
</div>
<div class="form-field string request_custom_fields_14922698922644 optional" hidden="">
<label id="request_custom_fields_14922698922644_label" for="request_custom_fields_14922698922644">Are you reaching out on behalf of yourself or someone else?</label>
<input type="hidden" name="request[custom_fields][14922698922644]" id="request_custom_fields_14922698922644" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Myself","value":"mef_contact_for_myself"},{"label":"Someone Else","value":"mef_contact_for_someone_else"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922698922644_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_7y0v2ru38" aria-required="true" aria-labelledby="request_custom_fields_14922698922644_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922700433812 optional" hidden="">
<label id="request_custom_fields_14922700433812_label" for="request_custom_fields_14922700433812">What billing issue can we help you with?</label>
<input type="hidden" name="request[custom_fields][14922700433812]" id="request_custom_fields_14922700433812" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Charge Dispute","value":"mef_billing_charge_dispute"},{"label":"Cost Estimate","value":"mef_billing_cost_estimate"},{"label":"Insurance","value":"mef_billing_insurance"},{"label":"Making a Payment","value":"mef_billing_making_a_payment"},{"label":"Missed/Cancelled Appointment Fee","value":"mef_billing_fees"},{"label":"Receipt Request","value":"mef_billing_receipt_request"},{"label":"Statement/Balance requests","value":"mef_billing_statement_balance_requests"},{"label":"Other","value":"mef_billing_nota"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922700433812_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_gzn1t0792" aria-required="true" aria-labelledby="request_custom_fields_14922700433812_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_9722637918228 optional" hidden="">
<label id="request_custom_fields_9722637918228_label" for="request_custom_fields_9722637918228">How should we contact you?</label>
<input type="hidden" name="request[custom_fields][9722637918228]" id="request_custom_fields_9722637918228" value="email_compass" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Email","value":"email_compass","selected":true},{"label":"Phone Call","value":"phone_call"}]"
aria-required="true" aria-labelledby="request_custom_fields_9722637918228_label"
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_4vggjpe5y" aria-required="true" aria-labelledby="request_custom_fields_9722637918228_label" style="max-width: 100%;">Email</a>
</div>
<div class="form-field string request_custom_fields_14922701416596 optional" hidden="">
<label id="request_custom_fields_14922701416596_label" for="request_custom_fields_14922701416596">What documentation do you need assistance with?</label>
<input type="hidden" name="request[custom_fields][14922701416596]" id="request_custom_fields_14922701416596" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Disability/Leave","value":"mef_docs_disability_leave"},{"label":"Records Requests/Other Letter Requests","value":"mef_docs_records"},{"label":"Minor Care Docs","value":"mef_docs_minor_care"},{"label":"Other","value":"mef_docs_other"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922701416596_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_m4ykw8gyr" aria-required="true" aria-labelledby="request_custom_fields_14922701416596_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922724699668 optional" hidden="">
<label id="request_custom_fields_14922724699668_label" for="request_custom_fields_14922724699668">Disability/Leave Documentation</label>
<input type="hidden" name="request[custom_fields][14922724699668]" id="request_custom_fields_14922724699668" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"FMLA","value":"mef_fmla"},{"label":"Long-Term Disability","value":"mef_longterm_disability"},{"label":"Return to Work","value":"mef_return_to_work"},{"label":"Short-Term Disability","value":"mef_shortterm_disability"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922724699668_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_duwpn3ub0" aria-required="true" aria-labelledby="request_custom_fields_14922724699668_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922738177556 optional" hidden="">
<label id="request_custom_fields_14922738177556_label" for="request_custom_fields_14922738177556">Minor Care Documentation</label>
<input type="hidden" name="request[custom_fields][14922738177556]" id="request_custom_fields_14922738177556" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Guardianship Paperwork","value":"mef_custody_paperwork"},{"label":"Informed Consents","value":"mef_informed_consents"},{"label":"Release of Information for Parent Contact for Minors","value":"mef_rois_for_parent_contact_for_minors"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922738177556_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_sh25lmwnp" aria-required="true" aria-labelledby="request_custom_fields_14922738177556_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922687633812 optional" hidden="">
<label id="request_custom_fields_14922687633812_label" for="request_custom_fields_14922687633812">Documentation / Records Requests</label>
<input type="hidden" name="request[custom_fields][14922687633812]" id="request_custom_fields_14922687633812" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Lab Request","value":"mef_lab_request"},{"label":"Records Requests","value":"mef_records_requests"},{"label":"Release of Information","value":"mef_rois_for_cross-provider_discussion"},{"label":"Other Provider Letters","value":"mef_other_provider_letters"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922687633812_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_8v6z3cwt8" aria-required="true" aria-labelledby="request_custom_fields_14922687633812_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922728927380 optional" hidden="">
<label id="request_custom_fields_14922728927380_label" for="request_custom_fields_14922728927380">What are you experiencing issues with?</label>
<input type="hidden" name="request[custom_fields][14922728927380]" id="request_custom_fields_14922728927380" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Sign-in","value":"mef_tech_signin"},{"label":"Zoom","value":"mef_tech_zoom"},{"label":"Scheduling","value":"mef_tech_scheduling"},{"label":"Assessment","value":"mef_tech_assessment"},{"label":"Moments","value":"mef_tech_moments"},{"label":"Other","value":"mef_tech_other"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922728927380_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_rru8bxvmk" aria-required="true" aria-labelledby="request_custom_fields_14922728927380_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922750054164 optional" hidden="">
<label id="request_custom_fields_14922750054164_label" for="request_custom_fields_14922750054164">What do you need assistance with?</label>
<input type="hidden" name="request[custom_fields][14922750054164]" id="request_custom_fields_14922750054164" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Requesting a new appointment","value":"mef_schedule_new"},{"label":"Reschedule/Cancel existing appointment","value":"mef_schedule_existing"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922750054164_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_fny824or0" aria-required="true" aria-labelledby="request_custom_fields_14922750054164_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_15133576538772 optional" hidden="">
<label id="request_custom_fields_15133576538772_label" for="request_custom_fields_15133576538772">Appointment Method</label>
<input type="hidden" name="request[custom_fields][15133576538772]" id="request_custom_fields_15133576538772" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"In Person","value":"in_person_therapy"},{"label":"Virtual","value":"virtual_therapy"}]"
aria-required="true" aria-labelledby="request_custom_fields_15133576538772_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_p0yo6nzg1" aria-required="true" aria-labelledby="request_custom_fields_15133576538772_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_11602308039188 optional" hidden="">
<label id="request_custom_fields_11602308039188_label" for="request_custom_fields_11602308039188">Member Type</label>
<input type="hidden" name="request[custom_fields][11602308039188]" id="request_custom_fields_11602308039188" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Adult","value":"mt_adult"},{"label":"Minor","value":"mt_minor"}]"
aria-required="true" aria-describedby="request_custom_fields_11602308039188_hint" aria-labelledby="request_custom_fields_11602308039188_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_gg9d98qq5" aria-required="true" aria-labelledby="request_custom_fields_11602308039188_label" aria-describedby="request_custom_fields_11602308039188_hint" style="max-width: 100%;">-</a>
<p id="request_custom_fields_11602308039188_hint">Who is this appointment for?</p>
</div>
<div class="form-field string request_custom_fields_14922783334548 optional" hidden="">
<label id="request_custom_fields_14922783334548_label" for="request_custom_fields_14922783334548">Type of appointment</label>
<input type="hidden" name="request[custom_fields][14922783334548]" id="request_custom_fields_14922783334548" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Adult Therapy","value":"adult_therapy"},{"label":"Couple Therapy","value":"adult_couples_therapy"},{"label":"Family Therapy","value":"adult_family_therapy"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922783334548_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_a20volocg" aria-required="true" aria-labelledby="request_custom_fields_14922783334548_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922769869076 optional" hidden="">
<label id="request_custom_fields_14922769869076_label" for="request_custom_fields_14922769869076">Type of appointment</label>
<input type="hidden" name="request[custom_fields][14922769869076]" id="request_custom_fields_14922769869076" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Minor Therapy","value":"minor_therapy"},{"label":"Care Navigation","value":"minor_care_navigation"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922769869076_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_sadjs9odz" aria-required="true" aria-labelledby="request_custom_fields_14922769869076_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922798881428 optional" hidden="">
<label id="request_custom_fields_14922798881428_label" for="request_custom_fields_14922798881428">Update type</label>
<input type="hidden" name="request[custom_fields][14922798881428]" id="request_custom_fields_14922798881428" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Reschedule appointment","value":"mef_reschedule_appointment"},{"label":"Cancel appointment","value":"mef_cancel_appointment"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922798881428_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_is5krhji8" aria-required="true" aria-labelledby="request_custom_fields_14922798881428_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_13039757161748 optional" hidden="">
<label id="request_custom_fields_13039757161748_label" for="request_custom_fields_13039757161748">Start Time of Appointment</label>
<input type="text" name="request[custom_fields][13039757161748]" id="request_custom_fields_13039757161748" aria-required="true" aria-describedby="request_custom_fields_13039757161748_hint"
aria-labelledby="request_custom_fields_13039757161748_label" disabled="">
<p id="request_custom_fields_13039757161748_hint">(include time zone)</p>
</div>
<div class="form-field string optional request_custom_fields_11602033134612" hidden="">
<label id="request_custom_fields_11602033134612_label" for="request_custom_fields_11602033134612">Date of Appointment</label>
<input type="text" class="datepicker" value="" disabled=""><input type="text" name="request[custom_fields][11602033134612]" id="request_custom_fields_11602033134612" data-datepicker="" data-format="YYYY-MM-DD" class="" aria-required="false"
aria-labelledby="request_custom_fields_11602033134612_label" readonly="readonly" style="display: none;" disabled="">
</div>
<div class="form-field string optional request_custom_fields_15038001292436" hidden="">
<label id="request_custom_fields_15038001292436_label" for="request_custom_fields_15038001292436">Reason for rescheduling</label>
<input type="hidden" name="request[custom_fields][15038001292436]" id="request_custom_fields_15038001292436" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Illness","value":"member_illness_eu_form"},{"label":"Scheduling conflict","value":"scheduling_conflict_eu_form"},{"label":"Forgot about appointment","value":"forgot_eu_form"},{"label":"Family or Work obligation","value":"family_or_work_obligation_eu_form"},{"label":"I was out of state","value":"member_out_of_state_eu_form"},{"label":"Other reason (please explain)","value":"other_reason__please_explain_eu_form"}]"
aria-required="false" aria-labelledby="request_custom_fields_15038001292436_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_ltol81tzk" aria-required="false" aria-labelledby="request_custom_fields_15038001292436_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922814973332 optional" hidden="">
<label id="request_custom_fields_14922814973332_label" for="request_custom_fields_14922814973332">Please share your availability and any preferences you have for your Provider</label>
<input type="text" class="datepicker" value="" disabled=""><input type="text" name="request[custom_fields][14922814973332]" id="request_custom_fields_14922814973332" data-datepicker="" data-format="YYYY-MM-DD" class="" aria-required="true"
aria-labelledby="request_custom_fields_14922814973332_label" readonly="readonly" style="display: none;" disabled="">
</div>
<div class="form-field string request_custom_fields_15133686174100 optional" hidden="">
<label id="request_custom_fields_15133686174100_label" for="request_custom_fields_15133686174100">What time of day would you like to meet?</label>
<input type="hidden" name="request[custom_fields][15133686174100]" id="request_custom_fields_15133686174100" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"Morning","value":"appointment_time_morning"},{"label":"Afternoon","value":"appointment_time_afternoon"},{"label":"Evening","value":"appointment_time_evening"},{"label":"I'm Flexible","value":"appointment_time_flexible"}]"
aria-required="true" aria-labelledby="request_custom_fields_15133686174100_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_xv1qwjrso" aria-required="true" aria-labelledby="request_custom_fields_15133686174100_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922835580692 optional" hidden="">
<label id="request_custom_fields_14922835580692_label" for="request_custom_fields_14922835580692">What issue is this concerning?</label>
<input type="hidden" name="request[custom_fields][14922835580692]" id="request_custom_fields_14922835580692" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"When will I be billed?","value":"mef_when_will_i_be_billed"},{"label":"Where can I see my balance?","value":"mef_wheres_my_balance"},{"label":"How many sessions to do I have remaining?","value":"mef_how_many_remaining_sessions"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922835580692_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_ogjgnz4mv" aria-required="true" aria-labelledby="request_custom_fields_14922835580692_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922818284180 optional" hidden="">
<label id="request_custom_fields_14922818284180_label" for="request_custom_fields_14922818284180">What issue is this concerning?</label>
<input type="hidden" name="request[custom_fields][14922818284180]" id="request_custom_fields_14922818284180" autocomplete="off"
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Skip to main content * Sign in * * * Submit a request * SUBMIT A REQUEST Please choose a request type below Member Support Form- Default Ticket Form Appointment Cancellation/Reschedule Form (Providers & Members) Inbound Referral Appointment Cancellation/Reschedule Form (Coaching) Member Support Form Critical Incident Response Intake Form Please enter the email address associated with your Spring Health account if you do not have a Spring Health account, please enter the email address associated with your benefit Add your desired Subject text for the specific form here What can we help you with? - Are you a Customer or Employer? - Is your insurance on file? - If not, please attach a picture on this form Are you reaching out on behalf of yourself or someone else? - What billing issue can we help you with? - How should we contact you? Email What documentation do you need assistance with? - Disability/Leave Documentation - Minor Care Documentation - Documentation / Records Requests - What are you experiencing issues with? - What do you need assistance with? - Appointment Method - Member Type - Who is this appointment for? Type of appointment - Type of appointment - Update type - Start Time of Appointment (include time zone) Date of Appointment Reason for rescheduling - Please share your availability and any preferences you have for your Provider What time of day would you like to meet? - What issue is this concerning? - What issue is this concerning? - How can we help? - What issue is this concerning? - What issue is this concerning? - How can we help? - Who is your Insurance Provider? What is your Member ID#? Are you signing up yourself or a dependent? - Are you the primary holder or a dependent? - What is the legal first name for the account? What is the legal last name for the account? What is your current address? What is your personal phone number? What is the date of birth for the account? How can we help? - If you’re experiencing severe symptoms that might be related to your medication, call 911 or go to the nearest emergency room. If you need crisis support at any time, please call the Spring Health Crisis Line by dialing 1 (855) 629-0554 (choose option 2). Severe symptoms can include, but is not limited to: chest pain, sudden hives, significant stiffness in muscles, sudden high fever, loss of speech, significant uncontrollable shaking. What medication are you seeking to refill? Is there anything else you would like to share? Normal textHeader 2Header 3Header 4 Please enter all relevant details here Upload attachments Add file or drop files here Spring Health