Service Request Form
Use this form to request service with any issue.
Agent Name
*
Agent Email
*
example@example.com
Priority Level
Critical Issue (Client out of meds or needs to schedule a Doctors appointment ASAP)
Normal Issue (Problem needs attention, but not critical)
Client First and Last Name
Client ID if known
If this pertains to a specific carrier, indicate which one?
Blue Cross
Globalhealth / Generations
Humana
Unitedhealthcare
Aetna / Coventry
Christus
Communitycare
Presbyterian
Other
If "Other" please specify:
What is the problem?
Not received ID Card
Members plan not in effect
RX Claim Issue
Medical Claim Issue
Agent Contracting Issue
Commission Issue
Other - please indicate below
Please let us know the problem in a few words:
Upload supporting documents here
Upload a File
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