Please complete this form and one of our agents will reply to you by email as soon as possible.
If you are a Behavioral Coach, please use 0000000000 NOTE: if you are a Therapist and do not have an NPI Please go to https://nppes.cms.hhs.gov/ and follow the instructions on the left to apply.
Must be 10 Characters Minimum Must have at least 1 Symbol Must have at least 1 Uppercase Must have at least 1 Lowercase Must have at least 1 Number Cannot Contain your username This will only be used to initially log in and set your permanent password.
Please fill in the blank with your referral reason.
Please fill in the blank with your recommendations for the Participant (e.g., behavioral health CM oversight, support groups, specialty resources/providers, etc.).
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
**If no participant ID, enter member health plan ID
Please select one.
If the product is Therapy +, please mirror the Therapist date/time above.
The reason for this leave request is (select the most appropriate box):
Type in your name. This represents your signature.
Describe the nature, extent and duration of your disability.
Describe the accommodations you believe are needed to enable you to perform the essential functions of this job.
Attach any supporting documentation below that may be helpful in evaluating this request for accommodation.
For example ( IC, 1A, 1B) **If there are multiple reschedules for the same Participant, please add details in the "Message" box below.
For example (IC, 1A, 1B)
If yes, please include rescheduling information in the message box below.
Type of treatment change
Member's current health plan
Please explain in detail what you are facing.
Please put scheduling details in message box below
You can't submit without there being a value in this field. (Limit one Participant ID per ticket)
Please use "message" box for additional details if needed.