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Please complete this form and one of our agents will reply to you by email as soon as possible.

You can't submit without there being a value in this field. (Limit one Participant ID per ticket)

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):

Additional information about employee leave of absence rights (including FMLA) and responsibilities will be provided to you in writing within five business days after receipt of this notice (unless already provided). Determination of eligibility for leave under FMLA and other leave of absence laws and/or additional documentation or clarification of documentation, may be required prior to making a final determination to approve any leave request. Please contact People Operations with any questions. Please return this form with documentation supporting your request for a leave of absence. (physician’s statement, military orders, or additional information)

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.

By Clicking 'Submit' I authorize the release of information regarding my disability to AbleTo management as deemed necessary by human resources to facilitate this request for accommodation. Depending on the accommodation, we may request health care provider information in regards to your impairment/disability and recommendations for accommodations. 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.


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