Provider Contact Form

Provider Contact Form

If you are a Total Life, and are in need of assistance from the Total Life team, please fill in the information requested and your inquiry will be reviewed as soon as possible. Please keep an eye on your e-mail if any response is needed.
Your Name*

First NameLast Name
Email Address*
example@example.com
What is the nature of your escalation?*

Client ReassignmentClinical ConsultationTechnical SupportPayroll InquiryCredentialing & LicensesRisk ReportRequest a MeetingDirect Deposit ChangeContact Information UpdateOther
What is your role at Total Life?*

Total Life ProviderCare Coordinator
What is the nature of your escalation?*

Client ComplaintProvider Feedback FormRisk ReportOther
Client ID*
What date will the client be ready for reassignment?*

MonthDayYear
Date should be after the date of your final session with the client.
Please explain the reason for the reassignment:*
What specialties & modalities should the next clinician possess?*
What type of clinician would be best for this client (ex. gender, experience, etc.)*
Have you filled out an Internal Transfer Note on the client's Profile?*

Yes
* Please note that this does NOT replace the Internal Transfer Note in the clients profile - please complete the Internal Transfer Note before submitting this form.
Date the incident occurred:

MonthDayYear
Date
Client ID
What is the nature of the complaint? Select all that apply:*

Provider's ActionsTotal Life Staff ActionsTechnical IssuesOther
Provider's Name*
Please provide details about the complaint:*
Provide a screenshot or other context: (Optional)

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Client ID*
Please describe the current challenges with your client case: *
Please do not include client names or any identifying information.
Which option best reflects your communication with this client so far?*

I have met with the client many timesI have met with the client a few timesI have met with the client onceI have not met with the client yet
Please describe your technical issue:*
Please upload a screenshot if applicable:

Please redact any private information before uploading.
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Please select the pay date you are inquiring about:*

MonthDayYear
Date
Have all of your charting notes been completed & locked for this period?*

YesNo
Refer to https://learning.totallife.com/provider-home for all pay dates, periods & cut off dates for documentation.

Please allow 24 hours from the expected pay date for your deposit to be received.
Please describe your payroll inquiry:*
Please do not include any personal information. You can include client IDs if needed.
Please select one:*

Updating Expired License & Other Expiry InquiriesOther Credential/Licensing Question
Please upload your document here:*

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Please describe what you are uploading:*
Please describe your inquiry for our credentialing department:*
Please do not include any personal information.
Who are you filling out a risk report for?*

Non-Client (No Total Life provider is currently assigned)Active Client (Currently assigned to a Total Life provider)
Please text & e-mail the client emergency & crisis resources. Call the client's local 911 if this is an emergency and provide whatever information you have for that client to emergency operators. We do not have a crisis team.

This form is for record-keeping only and should be submitted only after taking the steps above.
Client ID*
Provider's Name*
Provider Notified*

YesNo (Explain Why Below)
When did the incident occur?*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
What communication was used during this interaction?*

Phone CallVoicemailWritten E-MailWritten SMS
Please provide as many as details you can:*
Include things like client's address, actions taken (if police were called for a wellness check), what information & resources were sent to the client, etc.
What is the meeting topic?*
Please do not include personal information.
Appointment*
What type of provider feedback is this?*

ComplaintCommentPositive Feedback
Provider's Name*
Details:*
Please do not include any personal information.
Name of Bank*
Address of Bank*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name on Account*
Routing Number*
Account Number*
Business or Personal Account*
Checking or Savings*
Upload Banking Information or Void Check:*

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Signature*

Clear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will you be conducting sessions from a different location than your home address?*

YesNo
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provider any other updates or details below:
If applicable, please upload any corresponding documents below:

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To report any problems with this form, please e-mail providersuccess@totallife.com
Should be Empty: