Referral Support

Referral Support

You can also access support at support@totallife.com or by calling our care team directly at 1-800-567-LIFE.
Your First Name*
Your Last Name*
Your Email*
example@example.com
Your Fax Number
Please enter a valid phone number.
Your Phone Number*
Please enter a valid phone number.
Patient's Primary Care Physician*
Referring Doctor/Organization Name*

Patient Details

Please input as many as you can of the following details on the patient to assist our team in our process as we thoroughly investigate the issue
Patient First Name
Patient Last Name
Patient Email
Please enter a valid email address
Patient Phone Number
Please enter a valid phone number
Home State
Medicare Beneficiary Identifier (MBI)
Please enter the patients MBI number

Please outline your reason for submitting this ticket below*
Should be Empty: