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Submitter's Relationship to Member
...
Self
Dependent (Adult Dependent or Domestic Partner)
Benefits Administrator
Insurance Provider
Partnered Vendor
Evive Employee
<label class=" required control-label cf_name_of_dependent_853170-label " for="helpdesk_ticket_cf_name_of_dependent_853170">Name of Dependent</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_dependent_853170]" id="helpdesk_ticket_custom_field_cf_name_of_dependent_853170" /> </div>
<label class=" required control-label cf_name_of_submitter_853170-label " for="helpdesk_ticket_cf_name_of_submitter_853170">Name of Submitter</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_submitter_853170" /> </div>
<label class=" required control-label cf_name_of_partnered_vendor_employer_to_submitter_853170-label " for="helpdesk_ticket_cf_name_of_partnered_vendor_employer_to_submitter_853170">Name of Submitter's Employer</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_partnered_vendor_employer_to_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_partnered_vendor_employer_to_submitter_853170" /> </div>
<label class=" required control-label cf_evive_product_external_853170-label " for="helpdesk_ticket_cf_evive_product_external_853170">Product</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_evive_product_external_853170]" id="helpdesk_ticket_custom_field_cf_evive_product_external_853170"><option value="">...</option> <option data-id="36000672579" value="MyEvive">MyEvive</option> <option data-id="36000672580" value="Evive Plan Choice">Evive Plan Choice</option> <option data-id="36000672581" value="Evive 360">Evive 360</option> <option data-id="36000674681" value="Best Match">Best Match</option> <option data-id="36000685501" value="Evive Reporting Dashboard">Evive Reporting Dashboard</option></select> </div>
<label class=" required control-label cf_name_of_submitter_853170-label " for="helpdesk_ticket_cf_name_of_submitter_853170">Name of Submitter</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_submitter_853170" /> </div>
<label class=" required control-label cf_name_of_partnered_vendor_employer_to_submitter_853170-label " for="helpdesk_ticket_cf_name_of_partnered_vendor_employer_to_submitter_853170">Name of Submitter's Employer</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_partnered_vendor_employer_to_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_partnered_vendor_employer_to_submitter_853170" /> </div>
<label class=" required control-label cf_evive_product_external_853170-label " for="helpdesk_ticket_cf_evive_product_external_853170">Product</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_evive_product_external_853170]" id="helpdesk_ticket_custom_field_cf_evive_product_external_853170"><option value="">...</option> <option data-id="36000672579" value="MyEvive">MyEvive</option> <option data-id="36000672580" value="Evive Plan Choice">Evive Plan Choice</option> <option data-id="36000672581" value="Evive 360">Evive 360</option> <option data-id="36000674681" value="Best Match">Best Match</option> <option data-id="36000685501" value="Evive Reporting Dashboard">Evive Reporting Dashboard</option></select> </div>
<label class=" required control-label cf_name_of_submitter_853170-label " for="helpdesk_ticket_cf_name_of_submitter_853170">Name of Submitter</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_submitter_853170" /> </div>
<label class=" required control-label cf_name_of_partnered_vendor_employer_to_submitter_853170-label " for="helpdesk_ticket_cf_name_of_partnered_vendor_employer_to_submitter_853170">Name of Submitter's Employer</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_partnered_vendor_employer_to_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_partnered_vendor_employer_to_submitter_853170" /> </div>
<label class=" required control-label cf_evive_product_external_853170-label " for="helpdesk_ticket_cf_evive_product_external_853170">Product</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_evive_product_external_853170]" id="helpdesk_ticket_custom_field_cf_evive_product_external_853170"><option value="">...</option> <option data-id="36000672579" value="MyEvive">MyEvive</option> <option data-id="36000672580" value="Evive Plan Choice">Evive Plan Choice</option> <option data-id="36000672581" value="Evive 360">Evive 360</option> <option data-id="36000674681" value="Best Match">Best Match</option> <option data-id="36000685501" value="Evive Reporting Dashboard">Evive Reporting Dashboard</option></select> </div>
<label class=" required control-label cf_name_of_evive_employee_submitter_853170-label " for="helpdesk_ticket_cf_name_of_evive_employee_submitter_853170">Name of Evive Employee (Submitter)</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_evive_employee_submitter_853170]" id="helpdesk_ticket_custom_field_cf_name_of_evive_employee_submitter_853170" /> </div>
<label class=" required control-label cf_issue_reporter_853170-label " for="helpdesk_ticket_cf_issue_reporter_853170">Issue Reported</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_issue_reporter_853170]" id="helpdesk_ticket_custom_field_cf_issue_reporter_853170"><option value="">...</option> <option data-id="36000670074" value="Internal">Internal</option> <option data-id="36000670075" value="External">External</option></select> </div>
<label class=" required control-label cf_evive_product_853170-label " for="helpdesk_ticket_cf_evive_product_853170">Evive Product</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_evive_product_853170]" id="helpdesk_ticket_custom_field_cf_evive_product_853170"><option value="">...</option> <option data-id="36000652969" value="360">360</option> <option data-id="36000652970" value="Plan Choice">Plan Choice</option> <option data-id="36000652971" value="MyEvive">MyEvive</option> <option data-id="36000655583" value="Best Match">Best Match</option> <option data-id="36000662586" value="Evive Inside">Evive Inside</option> <option data-id="36000667212" value="Evive Well">Evive Well</option> <option data-id="36000685502" value="Evive Reporting Dashboard">Evive Reporting Dashboard</option> <option data-id="36000702696" value="Notifications">Notifications</option> <option data-id="36000703557" value="Command Center">Command Center</option> <option data-id="36000814304" value="Internal Tool">Internal Tool</option></select> </div>
Member's Legal First Name
Member's Last Name
Member's Employee ID
Member's DOB MM/DD/YYYY
Company (Employer to Member)
Submitter's Email
Member's Email (if different from Submitter's Email)
Issue Summary
Activity/Screening, if inquiring about Activity Status
Date of Service, if inquiring about Activity Status MM/DD/YYYY
Date & Time of Issue Occurrence MM/DD HH:MM am/pm
Browser Used
Description (Steps to Recreate Issue, Screenshots) Note: Please do not include Personal Information (SSN, Address, etc).
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