Contact Us - Helpdesk

Med+ Initial Appt Availability *

Please provide several options with date, time, and Participant timezone for Participant availability for this initial Med+ appointment

Issue: *

Link to report if available

Member Last Name *

Member First Name *

Personal Email Address *

Legal First Name *

Legal Last Name *

If you have more than one last name, please provide the last name you prefer to use for your email.

Gender *

Phone Type *

Allow SMS? (Mobile Phone Required) *

Spanish Speaking? *

Degree (ex. Master of Social Work)

First Year of Related Work Experience (ex. 1999) *

NPI Number *

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.

Pick Temporary Password *

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.

Role *

Choose Supervisor: *

Laptop Type

Laptop ready by?

Remote Employee?

Participant First Name *

Participant Last Name *

Best time to contact Participant

Type of Referral *

The Participant requires this non-urgent referral because... *

Please fill in the blank with your referral reason.

The additional support of a case manager may be beneficial to this Participant. We are recommending the Participant be provided with… *

Please fill in the blank with your recommendations for the Participant (e.g., behavioral health CM oversight, support groups, specialty resources/providers, etc.).

Please list comorbid medical and behavioral health conditions *

Does the Participant Agree to the Requested Referral? *

Have you made any referrals for this participant (Only for Aetna BH referrals)? *

If you have made any referrals for this Participant, please list provider names and contact information; otherwise type N/A *

Please list Participant's Psychiatric Diagnoses (Only for Aetna BH and MAP referrals; otherwise, type N/A): *

Looker Report URL:

Is it okay to leave voicemail? *

Joyable Product

Program

Partner Name

Company Name *

User Email Address *

User Mobile Number

What date do you need these created by? (Note: Please provide minimum of 1 business day of notice) *

Standard trial accounts are one week long. Is this case an exception?

Participant Health Plan *

Is the participant enrolled in Medicaid? *

Age Range *

Gender ID *

Preferred Language *

Phone Access *

Yes or No

Internet/Computer Access *

Yes or No

Transportation Access *

Yes or No

Open to Religious Affiliated Organization *

Yes or No

Veteran *

Yes or No

Participant ID *

**If no participant ID, enter member health plan ID

Request type *

Please select one.

Should you be the assigned Therapist for treatment?

Product *

Behavior Coach

If the product is Therapy +, please mirror the Therapist date/time above.

:

Programs *

What kind of device are you using?

What do you see under "Can't access company resources?"

Urgency Level *

Does this need to be addressed within the next 24 hours? *

Best time to contact

:

Employee Type

Requested Leave Start Date

Estimated Return Date

The Reason for this Leave Request

The reason for this leave request is (select the most appropriate box):

Birth of a son or daughter and to care for the newborn child. Placement with the employee of a son or daughter for adoption or foster care. To care for the employee's spouse, son, daughter or parent with a serious health condition. A serious health condition that makes the employee unable to perform the functions of the employee's job. COVID related illness or caregiving responsibilities A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status). To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered service member. To care for the employee’s child when the employee is unable to work (or telework) due to the closing of the child’s school, place of care, or unavailability of the regular childcare provider due to a public health emergency with respect to COVID-19. Other: Type In Message Box Below

Time Off Work Expected To Be

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)

Employee Signature *

Type in your name. This represents your signature.

Your Phone Number

City/State *

Supervisor Name

Description of Disability *

Describe the nature, extent and duration of your disability.

Describe Accommodations *

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.

Session to be rescheduled? *

For example ( IC, 1A, 1B) **If there are multiple reschedules for the same Participant, please add details in the "Message" box below.

Reassignment Role *

Upcoming Session *

For example (IC, 1A, 1B)

Do session(s) also need to be rescheduled? *

If yes, please include rescheduling information in the message box below.

Reassignment Reason *

Other Schedule request needed *

Date/Time *

:

Time Zone *

Type of Change? *

Change requested? *

Type of request *

Type of treatment change

Participant ID (Mandatory) *

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

Mail Request *

Which System? *

Duplicate ID *

Master ID *

Participant Email *

Date Of Birth *

Street *

City *

State *

Zip Code *

Health Plan *

Member's current health plan

Health plan ID *

Type of device being used: *

What browser type are you using? *

What occurred? *

Please explain in detail what you are facing.

What did you expect to occur? *

Name of Prescription/Pharmacy *

Reported symptoms *

Date/time side effects began *

Billing/Eligibility Question *

Department *

User First Name *

User Last Name *

Phone Number *

Participant ID (numbers only)

Med+ Role *

Med+ Scheduling request *

Please put scheduling details in message box below

Subject *

Message *

Name *

Email *

Category *