Cafe Health - Service Form

1

Name* This field is required.Please enter your first name and last name

First Name

Last Name

2

Email* This field is required.Please enter your email

example@example.com

3

Phone Number* This field is required.Please enter your phone number

Area Code

Phone Number

4

Employer* This field is required.Who is your employer?

Please enter the name of your current employer

5

Which Service Are You Calling About?* This field is required.

COBRA

Consumer Spending (FSA, HSA, HRA)

6

What’s the Main Issue?* This field is required.You selected COBRA

Login Issues

Carrier Re-instatement

Payments

General Questions

Other

7

What’s the Main Issue?* This field is required.You selected Consumer Spending

Account Balance

Debit Card

Claims Reimbursement

Login Issues

What can I use my card for?

How can I connect my bank account?

Other

8

Select your Debit Card issue.* This field is required.

I need a replacement

My debit card was declined

Other

9

Please provide a description below so we may better assist you(Optional)

10

Is Your Ticket Urgent?

YESNO