careteam.springhealth.com
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104.16.51.111
Public Scan
Submitted URL: https://links.springhealth.com/u/click?_t=accc26ce9d6f4136bb2575ae7b5f7f35&_m=8d7362d6274743ceabe88f3e7a399a97&_e=KhG-_...
Effective URL: https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=14448838263956
Submission: On July 06 via api from US — Scanned from DE
Effective URL: https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=14448838263956
Submission: On July 06 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET /hc/en-us/search
<form role="search" class="search" data-search="" data-instant="true" autocomplete="off" action="/hc/en-us/search" accept-charset="UTF-8" method="get"><input name="utf8" type="hidden" value="✓" autocomplete="off"><input type="search" name="query"
id="query" placeholder="Search" autocomplete="off" aria-label="Search"></form>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="_zqngdxfcf" aria-label="Please choose a request type below" style="max-width: 100%;">Member Support</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=4781340966292" value="4781340966292">Provider Support</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</option>
<option data-url="https://careteam.springhealth.com/hc/en-us/requests/new?ticket_form_id=15495106468116" value="15495106468116">Request for Management Consultation/ Referral/ Critical Incident Response</option>
</select>
</div>
<div class="form-field string required request_anonymous_requester_email"><label for="request_anonymous_requester_email">Your email address</label>
<input type="text" name="request[anonymous_requester_email]" id="request_anonymous_requester_email" aria-required="true">
</div>
<div class="form-field string required request_subject">
<label id="request_subject_label" for="request_subject">Subject</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="_l563gbgrj" aria-required="true" aria-labelledby="request_custom_fields_14922672270484_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="_ofigka25n" 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="_1dst17ia1" 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 Processing","value":"mef_billing_insurance"},{"label":"Making a Payment","value":"mef_billing_making_a_payment"},{"label":"Receipt Request","value":"mef_billing_receipt_request"},{"label":"Statement/Balance requests","value":"mef_billing_statement_balance_requests"},{"label":"Other","value":"mef_billing_notes"}]"
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="_42x8wnogg" aria-required="true" aria-labelledby="request_custom_fields_14922700433812_label" style="max-width: 100%;">-</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="_32sky996l" 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="_akkncj7sq" 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="_77z1p2em1" 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="_g21u5tl2l" 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":"Assessment","value":"mef_tech_assessment"},{"label":"Moments","value":"mef_tech_moments"}]"
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="_pq02ygmrt" 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="_k2j6ekm4e" 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="_nh4bgjyx9" 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="_6hua7toqn" 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="_nhejl4uja" 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="_zrjfq5api" 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="_qygxcea5l" aria-required="true" aria-labelledby="request_custom_fields_14922798881428_label" style="max-width: 100%;">-</a>
</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="_j33ob7uwc" 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="_kt41xltaj" 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="_zys4lp02m" 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"
data-tagger="[{"label":"-","value":""},{"label":"My payment link isn't working","value":"mef_broken_payment_link"},{"label":"Can I pay with an HSA/FSA?","value":"mef_pay_w_hsa_fsa"},{"label":"How do I pay for my balance?","value":"mef_pay_balance_how2"},{"label":"Can I set up automatic payments?","value":"mef_autopay_setup"},{"label":"Do you offer payment plans?","value":"mef_pay_via_paymentplan"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922818284180_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_j743lkyg6" aria-required="true" aria-labelledby="request_custom_fields_14922818284180_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922819165204 optional" hidden="">
<label id="request_custom_fields_14922819165204_label" for="request_custom_fields_14922819165204">How can we help?</label>
<input type="hidden" name="request[custom_fields][14922819165204]" id="request_custom_fields_14922819165204" autocomplete="off"
data-tagger="[{"label":"-","value":""},{"label":"I would to request a receipt","value":"mef_general_receipt_request"},{"label":"Can you provide a breakdown of charge?","value":"mef_charges_breakdown_request"},{"label":"Superbill/HCFA form","value":"mef_superbill_hcfa_form"}]"
aria-required="true" aria-labelledby="request_custom_fields_14922819165204_label" value=""
disabled=""><a class="nesty-input" tabindex="0" aria-haspopup="true" aria-expanded="false" aria-controls="_q6j7w054j" aria-required="true" aria-labelledby="request_custom_fields_14922819165204_label" style="max-width: 100%;">-</a>
</div>
<div class="form-field string request_custom_fields_14922858083220 optional" hidden="">
<label id="request_custom_fields_14922858083220_label" for="request_custom_fields_14922858083220">What issue is this concerning?</label>
<input type="hidden" name="request[custom_fields][14922858083220]" id="request_custom_fields_14922858083220" autocomplete="off"
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<p id="request_custom_fields_14922902311316_hint">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.
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</form>Text Content
Skip to main content Submit a request 1. Support Center 2. Submit a request SUBMIT A REQUEST Aim to include as much information and detail in your request as possible to reduce delays between replies Please choose a request type below Member Support- Default Ticket Form Provider Support Appointment Cancellation/Reschedule Form (Providers & Members) Inbound Referral Appointment Cancellation/Reschedule Form (Coaching) Member Support Request for Management Consultation/ Referral/ Critical Incident Response Your email address Subject What can we help you with? - 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? - 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 - 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? - Are you signing up yourself or a dependent? - Are you the primary holder or a dependent? - What is the full legal name for the account? What is the preferred full name for the account? 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? Who is your Insurance Provider? What is your Member ID#? Who is your employer? Description Please enter all relevant details here Attachments(optional) Add file or drop files here © Spring Health Return to top