Submit a request

These forms are ONLY for inquiries from Healthcare Facilities. If you are a Healthcare Professional, you can contact our Support team directly through the “Start a Chat” option in your Clipboard Health app. If you have trouble logging in, please select “Technical Issues” from the dropdown below.

First Name

Last Name

You may be entitled to assistance with medical costs related to your injury if you seek medical treatment.

(Select all that apply)

First Name

Last Name

Please enter the details of your request. A member of our support staff will respond as soon as possible.

As shown in mobile app

example@exmple.com

Workplace/Facility contact person phone number

example@example.com

Add file or drop files here