Increased patient use of O+POSITIVE blood has caused an increased need for donors. Donate now!
Please complete all information requested on the form. Missing information may delay the process of the claim. If you have any questions, contact Patient Claims at (504)592-1533
<br> <br>
The Blood Center will review the form, then process the claim for payment.
<br><br>
Alternatively, you can also print out and submit a paper form: <a href="https://cms.thebloodcenter.org/sites/default/files/2020-08/BloodAssuranceClaimForm.pdf">Click here to download the form.</a>
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<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_40" name="q40_name40[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_40 sublabel_40_first" />
<label class="form-sub-label" for="first_40" id="sublabel_40_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_40" name="q40_name40[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_40 sublabel_40_last" />
<label class="form-sub-label" for="last_40" id="sublabel_40_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_62">
<label class="form-label form-label-top form-label-auto" id="label_62" for="input_62_full"> Phone Number </label>
<div id="cid_62" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_62_full" name="q62_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_62 sublabel_62_masked" />
<label class="form-sub-label" for="input_62_full" id="sublabel_62_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_41">
<label class="form-label form-label-top form-label-auto" id="label_41" for="lite_mode_41"> Date of Birth </label>
<div id="cid_41" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_41" name="q41_dateOf41[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_41" id="sublabel_41_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_41" name="q41_dateOf41[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_41" id="sublabel_41_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_41" name="q41_dateOf41[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_year" />
<label class="form-sub-label" for="year_41" id="sublabel_41_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_41" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_41 sublabel_41_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_41_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_41" id="sublabel_41_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_address" id="id_42">
<label class="form-label form-label-top form-label-auto" id="label_42" for="input_42_addr_line1"> Address </label>
<div id="cid_42" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line1" name="q42_address42[addr_line1]" class="form-textbox form-address-line" value="" data-component="address_line_1" aria-labelledby="label_42 sublabel_42_addr_line1" required="" />
<label class="form-sub-label" for="input_42_addr_line1" id="sublabel_42_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line2" name="q42_address42[addr_line2]" class="form-textbox form-address-line" value="" data-component="address_line_2" aria-labelledby="label_42 sublabel_42_addr_line2" />
<label class="form-sub-label" for="input_42_addr_line2" id="sublabel_42_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-city-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_city" name="q42_address42[city]" class="form-textbox form-address-city" value="" data-component="city" aria-labelledby="label_42 sublabel_42_city" required="" />
<label class="form-sub-label" for="input_42_city" id="sublabel_42_city" style="min-height:13px" aria-hidden="false"> City </label>
</span>
</span>
<span class="form-address-line form-address-state-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_state" name="q42_address42[state]" class="form-textbox form-address-state" value="" data-component="state" aria-labelledby="label_42 sublabel_42_state" required="" />
<label class="form-sub-label" for="input_42_state" id="sublabel_42_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-zip-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_postal" name="q42_address42[postal]" class="form-textbox form-address-postal" value="" data-component="zip" aria-labelledby="label_42 sublabel_42_postal" required="" />
<label class="form-sub-label" for="input_42_postal" id="sublabel_42_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label>
</span>
</span>
</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_44">
<div id="cid_44" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_5">
<div id="cid_5" class="form-input-wide" data-layout="full">
<div id="text_5" class="form-html" data-component="text">
<p><span style="font-weight: bold; color: #2c2e35;">DONOR IN</span><span style="font-weight: bold; color: #2c2e35;">FORMATION </span><span style="font-weight: bold; color: #2c2e35;">(If </span><span style="font-weight: bold; color: #2c2e35;">diff</span><span style="font-weight: bold; color: #2c2e35;">erent</span> <span style="font-weight: bold; color: #2c2e35;">from </span><span style="font-weight: bold; color: #2c2e35;">pat</span><span style="font-weight: bold; color: #2c2e35;">i</span><span style="font-weight: bold; color: #2c2e35;">ent) </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_45">
<label class="form-label form-label-top form-label-auto" id="label_45" for="first_45"> Name </label>
<div id="cid_45" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_45" name="q45_name[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_45 sublabel_45_first" />
<label class="form-sub-label" for="first_45" id="sublabel_45_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_45" name="q45_name[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_45 sublabel_45_last" />
<label class="form-sub-label" for="last_45" id="sublabel_45_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_6">
<label class="form-label form-label-top form-label-auto" id="label_6" for="lite_mode_6"> Date of Birth: </label>
<div id="cid_6" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_6" name="q6_dateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_month" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="month_6" id="sublabel_6_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_6" name="q6_dateOf[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_day" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="day_6" id="sublabel_6_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_6" name="q6_dateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_year" />
<label class="form-sub-label" for="year_6" id="sublabel_6_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_6" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY" autoComplete="off" aria-labelledby="label_6 sublabel_6_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_6_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_6" id="sublabel_6_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_7">
<div id="cid_7" class="form-input-wide" data-layout="full">
<div id="text_7" class="form-html" data-component="text">
<p><span style="color: #2c2e35;">Don</span><span style="color: #2c2e35;">o</span><span style="color: #2c2e35;">r </span><span style="color: #2c2e35;">G</span><span style="color: #2c2e35;">r</span><span style="color: #2c2e35;">oup </span><span style="color: #2c2e35;">Affliation </span><span style="color: #2c2e35;">(if </span><span style="color: #2c2e35;">any): </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_8">
<label class="form-label form-label-top form-label-auto" id="label_8" for="input_8"> Donor Group Affiliation (if any): </label>
<div id="cid_8" class="form-input-wide" data-layout="half">
<input type="text" id="input_8" name="q8_donorGroup" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_8" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_46">
<div id="cid_46" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_9">
<div id="cid_9" class="form-input-wide" data-layout="full">
<div id="text_9" class="form-html" data-component="text">
<p><span style="font-weight: bold;color: #2c2e35;">CONTACT </span><span style="font-weight: bold;color: #2c2e35;">PE</span><span style="font-weight: bold;color: #2c2e35;">RSO</span><span style="font-weight: bold;color: #2c2e35;">N </span><span style="font-weight: bold;color: #2c2e35;">(</span><span style="font-weight: bold;color: #2c2e35;">If </span><span style="font-weight: bold;color: #2c2e35;">n</span><span style="font-weight: bold;color: #2c2e35;">ot </span><span style="font-weight: bold;color: #2c2e35;">pa</span><span style="font-weight: bold;color: #2c2e35;">tient)</span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_47">
<label class="form-label form-label-top form-label-auto" id="label_47" for="first_47"> Name </label>
<div id="cid_47" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_47" name="q47_name47[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_47 sublabel_47_first" />
<label class="form-sub-label" for="first_47" id="sublabel_47_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_47" name="q47_name47[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_47 sublabel_47_last" />
<label class="form-sub-label" for="last_47" id="sublabel_47_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_email" id="id_59">
<label class="form-label form-label-top form-label-auto" id="label_59" for="input_59"> Email </label>
<div id="cid_59" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="email" id="input_59" name="q59_email" class="form-textbox validate[Email]" style="width:310px" size="310" value="" data-component="email" aria-labelledby="label_59 sublabel_input_59" />
<label class="form-sub-label" for="input_59" id="sublabel_input_59" style="min-height:13px" aria-hidden="false"> example@example.com </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_48">
<label class="form-label form-label-top form-label-auto" id="label_48" for="input_48_full"> Phone Number </label>
<div id="cid_48" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_48_full" name="q48_phoneNumber48[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_48 sublabel_48_masked" />
<label class="form-sub-label" for="input_48_full" id="sublabel_48_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_11">
<label class="form-label form-label-top form-label-auto" id="label_11" for="input_11"> Relationship to Patient: </label>
<div id="cid_11" class="form-input-wide" data-layout="half">
<input type="text" id="input_11" name="q11_relationshipTo" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_11" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_49">
<div id="cid_49" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li id="cid_12" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_12" class="form-header" data-component="header">
INSURANCE INFORMATION
</h1>
</div>
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_51">
<label class="form-label form-label-top form-label-auto" id="label_51" for="input_51"> Does the patient have insurance? </label>
<div id="cid_51" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_51" data-component="radio">
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_0" name="q51_doesThe" value="Yes" />
<label id="label_input_51_0" for="input_51_0"> Yes </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_1" name="q51_doesThe" value="No" />
<label id="label_input_51_1" for="input_51_1"> No </label>
</span>
</div>
</div>
</li>
<li class="form-line form-field-hidden" style="display:none;" data-type="control_checkbox" id="id_60">
<label class="form-label form-label-top form-label-auto" id="label_60" for="input_60"> If yes, which provider? </label>
<div id="cid_60" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_60" data-component="checkbox">
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_0" name="q60_ifYes60[]" value="Medicare" />
<label id="label_input_60_0" for="input_60_0"> Medicare </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_1" name="q60_ifYes60[]" value="Medicade" />
<label id="label_input_60_1" for="input_60_1"> Medicade </label>
</span>
<span class="form-checkbox-item formCheckboxOther" style="clear:left">
<input type="checkbox" class="form-checkbox-other form-checkbox" name="q60_ifYes60[other]" id="other_60" value="other" aria-label="Other" />
<label id="label_other_60" style="text-indent:0" for="other_60"> Other </label>
<span id="other_60_input" class="other-input-container" style="display:none">
<input type="text" class="form-checkbox-other-input form-textbox" name="q60_ifYes60[other]" data-otherhint="Other" size="15" id="input_60" data-placeholder="Please type another option here" placeholder="Please type another option here" />
</span>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_16">
<div id="cid_16" class="form-input-wide" data-layout="full">
<div id="text_16" class="form-html" data-component="text">
<p><em>If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits</em></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_58">
<div id="cid_58" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_fileupload" id="id_63">
<label class="form-label form-label-top form-label-auto" id="label_63" for="input_63"> File Upload </label>
<div id="cid_63" class="form-input-wide" data-layout="full">
<div class="jfQuestion-fields" data-wrapper-react="true">
<div class="jfField isFilled">
<div class="jfUpload-wrapper">
<div class="jfUpload-container">
<div class="jfUpload-text-container">
<div class="jfUpload-icon forDesktop">
<span class="iconSvg dhtupload ">
<svg viewBox="0 0 54 47" version="1.1" xmlns="http://www.w3.org/2000/svg">
<g stroke="none" strokeWidth="1" fill="none">
<g transform="translate(-1506.000000, -2713.000000)">
<g transform="translate(1421.000000, 2713.000000)">
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<p style="text-align: center;"><strong>Please read and sign the release below: </strong></p>
<p><em>I hereby authorize the above-named hospital to release information regarding my blood product usage to The Blood Center. </em></p>
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<br> <br>
The Blood Center will review the form, then process the claim for payment.
<br><br>
Alternatively, you can also print out and submit a paper form: <a href="https://cms.thebloodcenter.org/sites/default/files/2020-08/BloodAssuranceClaimForm.pdf">Click here to download the form.</a>
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JotForm.prepareCalculationsOnTheFly([null,{"name":"bloodAssurance","qid":"1","text":"BLOOD ASSURANCE CLAIM FORM","type":"control_head"},{"name":"patientInformation","qid":"2","text":"PATIENT INFORMATION","type":"control_head"},null,null,{"name":"ltpgtltspanStylefontweight","qid":"5","text":"DONOR INFORMATION (If different from patient) ","type":"control_text"},{"description":"","name":"dateOf","qid":"6","text":"Date of Birth:","type":"control_datetime"},{"name":"ltpgtltspanStylecolor","qid":"7","text":"Donor Group Affliation (if any): ","type":"control_text"},{"description":"","name":"donorGroup","qid":"8","subLabel":"","text":"Donor Group Affiliation (if any):","type":"control_textbox"},{"name":"ltpgtltspanStylefontweight9","qid":"9","text":"CONTACT PERSON (If not patient)","type":"control_text"},null,{"description":"","name":"relationshipTo","qid":"11","subLabel":"","text":"Relationship to Patient:","type":"control_textbox"},{"name":"insuranceInformation","qid":"12","text":"INSURANCE INFORMATION","type":"control_head"},null,null,{"name":"hospitalInformation","qid":"15","text":"HOSPITAL INFORMATION","type":"control_head"},{"name":"ltpgtltspanStylecolor16","qid":"16","text":"If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits","type":"control_text"},{"description":"","name":"hospitalWhere","qid":"17","subLabel":"","text":"Hospital where services provided:","type":"control_textbox"},{"description":"","name":"location","qid":"18","subLabel":"","text":"Location:","type":"control_textbox"},{"description":"","name":"patientsHospital","qid":"19","subLabel":"","text":"Patient's Hospital ID# (or SSN):","type":"control_textbox"},{"description":"","name":"datesOf","qid":"20","text":"Dates of Service:","type":"control_datetime"},null,{"description":"","name":"patientSignature","qid":"22","subLabel":"","text":"Patient Signature:","type":"control_signature"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"name":"submit","qid":"39","text":"Submit","type":"control_button"},{"description":"","name":"name40","qid":"40","text":"Name","type":"control_fullname"},{"description":"","name":"dateOf41","qid":"41","text":"Date of Birth","type":"control_datetime"},{"description":"","name":"address42","qid":"42","text":"Address","type":"control_address"},null,{"name":"divider","qid":"44","type":"control_divider"},{"description":"","name":"name","qid":"45","text":"Name","type":"control_fullname"},{"name":"divider46","qid":"46","type":"control_divider"},{"description":"","name":"name47","qid":"47","text":"Name","type":"control_fullname"},{"description":"","name":"phoneNumber48","qid":"48","text":"Phone Number","type":"control_phone"},{"name":"divider49","qid":"49","type":"control_divider"},null,{"description":"","name":"doesThe","qid":"51","text":"Does the patient have insurance?","type":"control_radio"},null,null,null,null,{"name":"ltpgtltemgtifInsurance","qid":"56","text":"Please read and sign the release below: \nI hereby authorize the above-named hospital to release information regarding my blood product usage to The Blood Center. ","type":"control_text"},{"name":"divider57","qid":"57","type":"control_divider"},{"name":"divider58","qid":"58","type":"control_divider"},{"description":"","name":"email","qid":"59","subLabel":"example@example.com","text":"Email","type":"control_email"},{"description":"If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits","name":"ifYes60","qid":"60","text":"If yes, which provider?","type":"control_checkbox"},null,{"description":"","name":"phoneNumber","qid":"62","text":"Phone Number","type":"control_phone"},{"description":"","name":"fileUpload","qid":"63","subLabel":"Upload copy or picture of Explanation of Benefits (EOB)","text":"File Upload","type":"control_fileupload"}]);
setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,{"name":"bloodAssurance","qid":"1","text":"BLOOD ASSURANCE CLAIM FORM","type":"control_head"},{"name":"patientInformation","qid":"2","text":"PATIENT INFORMATION","type":"control_head"},null,null,{"name":"ltpgtltspanStylefontweight","qid":"5","text":"DONOR INFORMATION (If different from patient) ","type":"control_text"},{"description":"","name":"dateOf","qid":"6","text":"Date of Birth:","type":"control_datetime"},{"name":"ltpgtltspanStylecolor","qid":"7","text":"Donor Group Affliation (if any): ","type":"control_text"},{"description":"","name":"donorGroup","qid":"8","subLabel":"","text":"Donor Group Affiliation (if any):","type":"control_textbox"},{"name":"ltpgtltspanStylefontweight9","qid":"9","text":"CONTACT PERSON (If not patient)","type":"control_text"},null,{"description":"","name":"relationshipTo","qid":"11","subLabel":"","text":"Relationship to Patient:","type":"control_textbox"},{"name":"insuranceInformation","qid":"12","text":"INSURANCE INFORMATION","type":"control_head"},null,null,{"name":"hospitalInformation","qid":"15","text":"HOSPITAL INFORMATION","type":"control_head"},{"name":"ltpgtltspanStylecolor16","qid":"16","text":"If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits","type":"control_text"},{"description":"","name":"hospitalWhere","qid":"17","subLabel":"","text":"Hospital where services provided:","type":"control_textbox"},{"description":"","name":"location","qid":"18","subLabel":"","text":"Location:","type":"control_textbox"},{"description":"","name":"patientsHospital","qid":"19","subLabel":"","text":"Patient's Hospital ID# (or SSN):","type":"control_textbox"},{"description":"","name":"datesOf","qid":"20","text":"Dates of Service:","type":"control_datetime"},null,{"description":"","name":"patientSignature","qid":"22","subLabel":"","text":"Patient Signature:","type":"control_signature"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"name":"submit","qid":"39","text":"Submit","type":"control_button"},{"description":"","name":"name40","qid":"40","text":"Name","type":"control_fullname"},{"description":"","name":"dateOf41","qid":"41","text":"Date of Birth","type":"control_datetime"},{"description":"","name":"address42","qid":"42","text":"Address","type":"control_address"},null,{"name":"divider","qid":"44","type":"control_divider"},{"description":"","name":"name","qid":"45","text":"Name","type":"control_fullname"},{"name":"divider46","qid":"46","type":"control_divider"},{"description":"","name":"name47","qid":"47","text":"Name","type":"control_fullname"},{"description":"","name":"phoneNumber48","qid":"48","text":"Phone Number","type":"control_phone"},{"name":"divider49","qid":"49","type":"control_divider"},null,{"description":"","name":"doesThe","qid":"51","text":"Does the patient have insurance?","type":"control_radio"},null,null,null,null,{"name":"ltpgtltemgtifInsurance","qid":"56","text":"Please read and sign the release below: \nI hereby authorize the above-named hospital to release information regarding my blood product usage to The Blood Center. ","type":"control_text"},{"name":"divider57","qid":"57","type":"control_divider"},{"name":"divider58","qid":"58","type":"control_divider"},{"description":"","name":"email","qid":"59","subLabel":"example@example.com","text":"Email","type":"control_email"},{"description":"If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits","name":"ifYes60","qid":"60","text":"If yes, which provider?","type":"control_checkbox"},null,{"description":"","name":"phoneNumber","qid":"62","text":"Phone Number","type":"control_phone"},{"description":"","name":"fileUpload","qid":"63","subLabel":"Upload copy or picture of Explanation of Benefits (EOB)","text":"File Upload","type":"control_fileupload"}]);}, 20);
</script>
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/*__INSPECT_SEPERATOR__*/
/* Injected CSS Code */
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<form class="jotform-form" action="https://hipaa.jotform.com/submit/202174582955057/" method="post" enctype="multipart/form-data" name="form_202174582955057" id="202174582955057" accept-charset="utf-8" autocomplete="off">
<input type="hidden" name="formID" value="202174582955057" />
<input type="hidden" id="JWTContainer" value="" />
<input type="hidden" id="cardinalOrderNumber" value="" />
<div role="main" class="form-all">
<div class="formLogoWrapper Left">
<img loading="lazy" class="formLogoImg" src="https://www.jotform.com/uploads/apaulable/form_files/TBC-Logo-Unstacked-Black.5f2adb10433153.07210213.png" height="140" width="523">
</div>
<style>
.formLogoWrapper { display:inline-block; position: absolute; width: 100%;} .form-all:before { background: none !important;} .formLogoWrapper.Left { top: -150px; left: 0; text-align: left;}
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<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httac htvam">
<h1 id="header_1" class="form-header" data-component="header">
BLOOD ASSURANCE CLAIM FORM
</h1>
</div>
</div>
</li>
<li id="cid_2" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_2" class="form-header" data-component="header">
PATIENT INFORMATION
</h1>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_40">
<label class="form-label form-label-top form-label-auto" id="label_40" for="first_40"> Name </label>
<div id="cid_40" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
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<label class="form-sub-label" for="first_40" id="sublabel_40_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_40" name="q40_name40[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_40 sublabel_40_last" />
<label class="form-sub-label" for="last_40" id="sublabel_40_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_62">
<label class="form-label form-label-top form-label-auto" id="label_62" for="input_62_full"> Phone Number </label>
<div id="cid_62" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_62_full" name="q62_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_62 sublabel_62_masked" />
<label class="form-sub-label" for="input_62_full" id="sublabel_62_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_41">
<label class="form-label form-label-top form-label-auto" id="label_41" for="lite_mode_41"> Date of Birth </label>
<div id="cid_41" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
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<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_41" id="sublabel_41_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_41" name="q41_dateOf41[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_41" id="sublabel_41_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_41" name="q41_dateOf41[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_year" />
<label class="form-sub-label" for="year_41" id="sublabel_41_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_41" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_41 sublabel_41_litemode" />
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<label class="form-sub-label" for="lite_mode_41" id="sublabel_41_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_address" id="id_42">
<label class="form-label form-label-top form-label-auto" id="label_42" for="input_42_addr_line1"> Address </label>
<div id="cid_42" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line1" name="q42_address42[addr_line1]" class="form-textbox form-address-line" value="" data-component="address_line_1" aria-labelledby="label_42 sublabel_42_addr_line1" required="" />
<label class="form-sub-label" for="input_42_addr_line1" id="sublabel_42_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line2" name="q42_address42[addr_line2]" class="form-textbox form-address-line" value="" data-component="address_line_2" aria-labelledby="label_42 sublabel_42_addr_line2" />
<label class="form-sub-label" for="input_42_addr_line2" id="sublabel_42_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-city-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_city" name="q42_address42[city]" class="form-textbox form-address-city" value="" data-component="city" aria-labelledby="label_42 sublabel_42_city" required="" />
<label class="form-sub-label" for="input_42_city" id="sublabel_42_city" style="min-height:13px" aria-hidden="false"> City </label>
</span>
</span>
<span class="form-address-line form-address-state-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_state" name="q42_address42[state]" class="form-textbox form-address-state" value="" data-component="state" aria-labelledby="label_42 sublabel_42_state" required="" />
<label class="form-sub-label" for="input_42_state" id="sublabel_42_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-zip-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_postal" name="q42_address42[postal]" class="form-textbox form-address-postal" value="" data-component="zip" aria-labelledby="label_42 sublabel_42_postal" required="" />
<label class="form-sub-label" for="input_42_postal" id="sublabel_42_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label>
</span>
</span>
</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_44">
<div id="cid_44" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_5">
<div id="cid_5" class="form-input-wide" data-layout="full">
<div id="text_5" class="form-html" data-component="text">
<p><span style="font-weight: bold; color: #2c2e35;">DONOR IN</span><span style="font-weight: bold; color: #2c2e35;">FORMATION </span><span style="font-weight: bold; color: #2c2e35;">(If </span><span style="font-weight: bold; color: #2c2e35;">diff</span><span style="font-weight: bold; color: #2c2e35;">erent</span> <span style="font-weight: bold; color: #2c2e35;">from </span><span style="font-weight: bold; color: #2c2e35;">pat</span><span style="font-weight: bold; color: #2c2e35;">i</span><span style="font-weight: bold; color: #2c2e35;">ent) </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_45">
<label class="form-label form-label-top form-label-auto" id="label_45" for="first_45"> Name </label>
<div id="cid_45" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_45" name="q45_name[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_45 sublabel_45_first" />
<label class="form-sub-label" for="first_45" id="sublabel_45_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_45" name="q45_name[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_45 sublabel_45_last" />
<label class="form-sub-label" for="last_45" id="sublabel_45_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_6">
<label class="form-label form-label-top form-label-auto" id="label_6" for="lite_mode_6"> Date of Birth: </label>
<div id="cid_6" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_6" name="q6_dateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_month" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="month_6" id="sublabel_6_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_6" name="q6_dateOf[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_day" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="day_6" id="sublabel_6_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_6" name="q6_dateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_year" />
<label class="form-sub-label" for="year_6" id="sublabel_6_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_6" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY" autoComplete="off" aria-labelledby="label_6 sublabel_6_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_6_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_6" id="sublabel_6_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_7">
<div id="cid_7" class="form-input-wide" data-layout="full">
<div id="text_7" class="form-html" data-component="text">
<p><span style="color: #2c2e35;">Don</span><span style="color: #2c2e35;">o</span><span style="color: #2c2e35;">r </span><span style="color: #2c2e35;">G</span><span style="color: #2c2e35;">r</span><span style="color: #2c2e35;">oup </span><span style="color: #2c2e35;">Affliation </span><span style="color: #2c2e35;">(if </span><span style="color: #2c2e35;">any): </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_8">
<label class="form-label form-label-top form-label-auto" id="label_8" for="input_8"> Donor Group Affiliation (if any): </label>
<div id="cid_8" class="form-input-wide" data-layout="half">
<input type="text" id="input_8" name="q8_donorGroup" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_8" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_46">
<div id="cid_46" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_9">
<div id="cid_9" class="form-input-wide" data-layout="full">
<div id="text_9" class="form-html" data-component="text">
<p><span style="font-weight: bold;color: #2c2e35;">CONTACT </span><span style="font-weight: bold;color: #2c2e35;">PE</span><span style="font-weight: bold;color: #2c2e35;">RSO</span><span style="font-weight: bold;color: #2c2e35;">N </span><span style="font-weight: bold;color: #2c2e35;">(</span><span style="font-weight: bold;color: #2c2e35;">If </span><span style="font-weight: bold;color: #2c2e35;">n</span><span style="font-weight: bold;color: #2c2e35;">ot </span><span style="font-weight: bold;color: #2c2e35;">pa</span><span style="font-weight: bold;color: #2c2e35;">tient)</span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_47">
<label class="form-label form-label-top form-label-auto" id="label_47" for="first_47"> Name </label>
<div id="cid_47" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_47" name="q47_name47[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_47 sublabel_47_first" />
<label class="form-sub-label" for="first_47" id="sublabel_47_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_47" name="q47_name47[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_47 sublabel_47_last" />
<label class="form-sub-label" for="last_47" id="sublabel_47_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_email" id="id_59">
<label class="form-label form-label-top form-label-auto" id="label_59" for="input_59"> Email </label>
<div id="cid_59" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="email" id="input_59" name="q59_email" class="form-textbox validate[Email]" style="width:310px" size="310" value="" data-component="email" aria-labelledby="label_59 sublabel_input_59" />
<label class="form-sub-label" for="input_59" id="sublabel_input_59" style="min-height:13px" aria-hidden="false"> example@example.com </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_48">
<label class="form-label form-label-top form-label-auto" id="label_48" for="input_48_full"> Phone Number </label>
<div id="cid_48" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_48_full" name="q48_phoneNumber48[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_48 sublabel_48_masked" />
<label class="form-sub-label" for="input_48_full" id="sublabel_48_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_11">
<label class="form-label form-label-top form-label-auto" id="label_11" for="input_11"> Relationship to Patient: </label>
<div id="cid_11" class="form-input-wide" data-layout="half">
<input type="text" id="input_11" name="q11_relationshipTo" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_11" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_49">
<div id="cid_49" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li id="cid_12" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_12" class="form-header" data-component="header">
INSURANCE INFORMATION
</h1>
</div>
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_51">
<label class="form-label form-label-top form-label-auto" id="label_51" for="input_51"> Does the patient have insurance? </label>
<div id="cid_51" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_51" data-component="radio">
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_0" name="q51_doesThe" value="Yes" />
<label id="label_input_51_0" for="input_51_0"> Yes </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_1" name="q51_doesThe" value="No" />
<label id="label_input_51_1" for="input_51_1"> No </label>
</span>
</div>
</div>
</li>
<li class="form-line form-field-hidden" style="display:none;" data-type="control_checkbox" id="id_60">
<label class="form-label form-label-top form-label-auto" id="label_60" for="input_60"> If yes, which provider? </label>
<div id="cid_60" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_60" data-component="checkbox">
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_0" name="q60_ifYes60[]" value="Medicare" />
<label id="label_input_60_0" for="input_60_0"> Medicare </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_1" name="q60_ifYes60[]" value="Medicade" />
<label id="label_input_60_1" for="input_60_1"> Medicade </label>
</span>
<span class="form-checkbox-item formCheckboxOther" style="clear:left">
<input type="checkbox" class="form-checkbox-other form-checkbox" name="q60_ifYes60[other]" id="other_60" value="other" aria-label="Other" />
<label id="label_other_60" style="text-indent:0" for="other_60"> Other </label>
<span id="other_60_input" class="other-input-container" style="display:none">
<input type="text" class="form-checkbox-other-input form-textbox" name="q60_ifYes60[other]" data-otherhint="Other" size="15" id="input_60" data-placeholder="Please type another option here" placeholder="Please type another option here" />
</span>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_16">
<div id="cid_16" class="form-input-wide" data-layout="full">
<div id="text_16" class="form-html" data-component="text">
<p><em>If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits</em></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_58">
<div id="cid_58" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_fileupload" id="id_63">
<label class="form-label form-label-top form-label-auto" id="label_63" for="input_63"> File Upload </label>
<div id="cid_63" class="form-input-wide" data-layout="full">
<div class="jfQuestion-fields" data-wrapper-react="true">
<div class="jfField isFilled">
<div class="jfUpload-wrapper">
<div class="jfUpload-container">
<div class="jfUpload-text-container">
<div class="jfUpload-icon forDesktop">
<span class="iconSvg dhtupload ">
<svg viewBox="0 0 54 47" version="1.1" xmlns="http://www.w3.org/2000/svg">
<g stroke="none" strokeWidth="1" fill="none">
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Cancel
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of
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HOSPITAL INFORMATION
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/
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/
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<div id="text_56" class="form-html" data-component="text">
<p style="text-align: center;"><strong>Please read and sign the release below: </strong></p>
<p><em>I hereby authorize the above-named hospital to release information regarding my blood product usage to The Blood Center. </em></p>
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<li class="form-line" data-type="control_signature" id="id_22">
<label class="form-label form-label-top form-label-auto" id="label_22" for="input_22"> Patient Signature: </label>
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<div id="signature_pad_22" class="signature-pad-wrapper" style="width:312px;height:116px">
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<!--[if IE 7]>
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<![endif]-->
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<span class="clear-pad-btn clear-pad" role="button" tabindex="0">
Clear
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<div data-wrapper-react="true">
<script type="text/javascript">
window.signatureForm = true
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<li class="form-line" data-type="control_button" id="id_39">
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Preview PDF
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Submit
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</li>
<li style="display:none">
Should be Empty:
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