Submit a request – Spring Health

Please choose a request type below

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

Update type

Date of Appointment(optional)

Reason for rescheduling(optional)

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?

How can we help?

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?(optional)

Description

Please enter all relevant details here

Attachments(optional)

Add file or drop files here