{"id":54,"date":"2020-12-10T19:36:26","date_gmt":"2020-12-10T19:36:26","guid":{"rendered":"http:\/\/www.arrantsurgical.com\/?page_id=54"},"modified":"2020-12-10T19:36:26","modified_gmt":"2020-12-10T19:36:26","slug":"insurance-form","status":"publish","type":"page","link":"https:\/\/www.arrantsurgical.com\/index.php\/insurance-form\/","title":{"rendered":"Insurance Form"},"content":{"rendered":"\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-47\"><form id=\"wpforms-form-47\" class=\"wpforms-validate wpforms-form\" data-formid=\"47\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/54\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-47-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_9\">Patient Name<\/label><input type=\"text\" id=\"wpforms-47-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-47-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_1\">Primary Insurance Company<\/label><input type=\"text\" id=\"wpforms-47-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" ><\/div><div id=\"wpforms-47-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_3\">Patient ID #<\/label><input type=\"text\" id=\"wpforms-47-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-47-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_4\">Group #<\/label><input type=\"text\" id=\"wpforms-47-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-47-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_5\">Subscriber Name &amp; Relationship<\/label><input type=\"text\" id=\"wpforms-47-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/div><div id=\"wpforms-47-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_6\">DOB<\/label><input type=\"text\" id=\"wpforms-47-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" ><\/div><div id=\"wpforms-47-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_17\">Social Security #<\/label><input type=\"text\" id=\"wpforms-47-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-47-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_20\">Secondary Insurance (if applicable):<\/label><input type=\"text\" id=\"wpforms-47-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-47-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_21\">ID#<\/label><input type=\"text\" id=\"wpforms-47-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-47-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_23\">Group #<\/label><input type=\"text\" id=\"wpforms-47-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-47-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_24\">Pharmacy Information: (Name, Address, &amp; Phone Number)<\/label><textarea id=\"wpforms-47-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><\/textarea><\/div><div id=\"wpforms-47-field_12-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_12\">Is this a Workers Comp or No Fault Claim<\/label><ul id=\"wpforms-47-field_12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-47-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Workers Comp\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-47-field_12_1\">Workers Comp<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-47-field_12_2\" name=\"wpforms[fields][12][]\" value=\"No Fault\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-47-field_12_2\">No Fault<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-47-field_12_3\" name=\"wpforms[fields][12][]\" value=\"Neither\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-47-field_12_3\">Neither<\/label><\/li><\/ul><\/div><div id=\"wpforms-47-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_13\">If WC or NF, Please list Date of Injury:<\/label><input type=\"text\" id=\"wpforms-47-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-47-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_14\">WCB #<\/label><input type=\"text\" id=\"wpforms-47-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-47-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_15\">Insurance Claim #<\/label><input type=\"text\" id=\"wpforms-47-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-47-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_19\">Employer at time of Injury, Address, &amp; Phone Number:<\/label><textarea id=\"wpforms-47-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/textarea><\/div><div id=\"wpforms-47-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-47-field_25\">Attorney on Case (If Applicable):  Name, Address, &amp; Phone Number\/Fax  Number<\/label><textarea id=\"wpforms-47-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/textarea><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-47-field-hp\" class=\"wpforms-field-label\">Comment<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-47-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"47\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-47\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/pages\/54"}],"collection":[{"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/comments?post=54"}],"version-history":[{"count":1,"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/pages\/54\/revisions"}],"predecessor-version":[{"id":55,"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/pages\/54\/revisions\/55"}],"wp:attachment":[{"href":"https:\/\/www.arrantsurgical.com\/index.php\/wp-json\/wp\/v2\/media?parent=54"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}