Submit a request – Spring Health

Spring Health
Submit a request

Thank you for your referral. A member of the Spring Health Team will reach out to the individual, typically over email. Please share with the individual to expect outreach to the email provided.

Aim to include as much information and detail in your request as possible to reduce delays between replies

Please choose a request type below

Your email address

Subject

What can we help you with?

Provider’s Full name

Provider’s email address

Provider’s phone number(optional)

Provider’s physical/office address (if applicable)(optional)

Have you asked your provider if they are currently a Spring Health provider? (optional)

If they are not currently a Spring Health provider, have you let them know you are referring them to join our network?(optional)

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

Completion of this form does not guarantee a clinically appropriate diagnosis for leave of absence.

Have you already initiated your leave with your employer?(optional)

Have you already discussed taking a leave of absence with your Spring provider?(optional)

What is your provider's name?(optional)

If you have discussed leave of absence with your current provider, did your current provider state she/he/they could assist you with any required disability paperwork?(optional)

Have you filled out a Spring Health Release of Information (ROI) authorizing release of your medical records to your disability vendor?(optional)

Please attach a copy of your Disability/Leave paperwork.(optional)

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

Attachments(optional)

Add file or drop files here