Initial Ticket Intake Form Customer Service Intake & InformationInitial Call Date* MM slash DD slash YYYY Initial Call Time* : Hours Minutes AM PM AM/PM Ticket Number Please note that the field is optional. (Most people calling don't have a ticket number.)Caller Name* First Last Caller Phone No*Caller Email* Best Contact Method* Phone Email OK to Leave Message?* Yes No Is foreign language assistance required?* Yes No Language Needed* Client/Group Name & Toll-Free Number*Please refer to Client Line Name/Number.- Select One -247 Telemed [855-252-5694]ACTS [866-569-5967]Alert Protective Services [866-583-0163]AllTrust [855-370-2410]American Mortgage Consultants (Lykes) [844-398-9525]Benezon Demo Client [866-981-5789]BI-Lynch Oil [855-634-0300]BI-Pepper Contracting [855-634-0299]Bob Gearhart [855-252-5654]Bob Miller Masonry/BMMI [844-867-1914]Borislow Insurance [866-569-8261]Bouchard Insurance-Volunteers of America [866-572-3391]Bouchard-New South Windows [855-252-5693]Braden Benefits-Piedmont Clinics [855-233-9672]Captivated Health-GEI Consultants, Inc. [866-569-8260]Captivated Health-Nitsch Engineering [866-569-6079]Captivated Health-Woodard & Curran [866-569-8259]CH-Berwick Academy [855-370-8135]CH-Proctor Academy [855-370-8064]CH-Tower School [855-370-8091]Colliers International [866-569-1229]CompuLink (Bouchard) [844-398-9524]David Rine Insurance [855-233-9673]DCCU-NEMA [866-573-0224]DCCU-Taylor English [877-383-1243]EOI-Marsh Driver [855-729-0114]Global Financial Advisory (Lykes) [844-993-3114]Group Benefit Systems [866-216-9384]Gulf Electric Company (Lykes) [855-370-2408]Health Excellence Select [877-382-4976]Health Insurance Interactive [877-383-1243]Howard Fertilizer and Chemical Company [855-252-5695]Kirby Employee Benefits [866-216-7738]Lake Norman Benefits-IND [844-993-3112]LI-University Club [855-729-0111]LNB-Palmer Johnson Power [855-370-8138]Lykes Bros. [866-569-3412]Lykes Insurance-Accudata Integrated Marketing [855-233-9677]Lykes Insurance-Berkeley Prep School [855-233-9676]Lykes Insurance-General Line [855-233-9675]Lykes Insurance-Retro Elevator [855-233-9674]Lykes Insurance-Sleep International [866-569-6092]Lykes Insurance-Tampa Yacht Club [855-370-2410]MCS-CarePro 24/7 [844-398-9527]My Healthy US [877-383-9404]Petrotech Southeast (Lykes) [877-389-0058]QI-Qandun [855-729-0113]Rick Bailey & Co (Inrollit) [877-389-0057]RSC-Oakbridge [855-729-0112]Select Virtual Health [877-383-9417]TBB-Questige [855-634-0301]*Other [see comments]Subscriber Name(if different from caller name) Reason for Call (Open Ticket)Reason for Call*Access to CareAppealsAuthorization IssuesBenefit DiscussionClaims/BillingCostsEligibilityEnrollmentNetworkNon-Medical CoveragesOtherPharmacyTelemedicineDescription of Request*Please enter a brief description of the issue as presented by the caller.Other Notes (from the Tier 1 Advocate)Provide available demographic and policy data. (Please refer to script.)Note to CSP: Before you submit the ticket, please return to the script to patch the call. Once the patch attempt is completed, please return and submit the web form.NameThis field is for validation purposes and should be left unchanged.