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<!DOCTYPE html>
<!--
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and open the template in the editor.
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<html>
<head>
<title></title>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel='stylesheet' href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css">
<link rel='stylesheet' href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.0.3/css/font-awesome.css">
<link rel='stylesheet' href="css/custom.css">
</head>
<body>
<div class="container-fluid" id="grad1">
<div class="row justify-content-center mt-0">
<div class="col-11 col-sm-12 col-md-6 col-lg-12 text-center p-0 mb-2">
<div class="header col-md-12 display-flex">
<div class="logo col-md-8 text-left"><img src="images/logo_generic.png" width="210"></div>
<div class="search_bar col-md-4 display-flex float-right">
<div class="form-group">
<select class="select_patient form-control">
<option>Patient Enrollment Form</option>
</select>
</div>
<button class="btn btn-sm btn-primary">New Patient</button>
</div>
</div>
<div class="form-card card px-0 pb-0 mb-3">
<div class="form-header pt-4">
<h2><strong>Prescription and Patient Enrollment Form</strong></h2>
<p>Please complete this form and click the submit below. For assistance or additional information, call 1-202-555-0150, Monday - Friday, 8:00 am to 8:00 pm ET.</p>
</div>
<div class="row">
<div class="col-md-12 mx-0">
<form id="msform">
<!-- progressbar -->
<!-- <ul id="progressbar">
<li class="active" id="account"><strong>PATIENT INFORMATION</strong></li>
<li id="personal"><strong>Personal</strong></li>
<li id="payment"><strong>Payment</strong></li>
<li id="confirm"><strong>Finish</strong></li>
</ul>-->
<!-- fieldsets -->
<fieldset>
<div class="form-card">
<h2 class="fs-title">PATIENT INFORMATION</h2>
<div class="display-flex">
<div class="form-group col-md-4 col-12">
<!--<label>First Name</label>-->
<input type="text" name="fname" class="fname form-control" placeholder=""/>
<span class="floating-label">First Name</span>
</div>
<div class="form-group col-md-4 col-12">
<!--<label>Middle Name</label>-->
<input type="text" name="mname" class="mname form-control" placeholder="" />
<span class="floating-label">Middle Name</span>
</div>
<div class="form-group col-md-4 col-12">
<!--<label>Last Name</label>-->
<input type="text" name="lname" class="lname form-control" placeholder="" />
<span class="floating-label">Last Name</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12">
<label class="text-label">Date of birth (DOB)</label>
<input type="date" name="patient[dob]" class="patient_dob form-control" placeholder="Select date" />
</div>
<div class="form-group col-md-6 col-12">
<label class="text-label">Gender</label>
<div class="display-flex">
<div class="radio">
<label><input type="radio" name="patient[gender]" class="patGender" id="checkbox3" value="M">Male</label>
</div>
<div class="radio">
<label><input type="radio" name="patient[gender]" class="patGender" id="checkbox3" value="F">Female</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-12 col-12">
<!--<label>Address Line 1</label>-->
<input type="text" name="address_line1" class="address_line1 form-control" placeholder="" />
<span class="floating-label">Address Line 1</span>
</div>
<div class="form-group col-md-12 col-12">
<!--<label>Address Line 2</label>-->
<input type="text" name="address_line2" class="address_line2 form-control" placeholder="" />
<span class="floating-label">Address Line 2</span>
</div>
<div class="display-flex">
<div class="form-group col-md-4 col-12">
<input type="text" name="city" class="city form-control" placeholder="" />
<span class="floating-label">City</span>
</div>
<div class="form-group col-md-4 col-12">
<select class="list-dt form-control selectbox state" id="patient_state" name="patient[state]">
<option value=""></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
<span class="floating-label">State</span>
</div>
<div class="form-group col-md-4 col-12">
<input type="text" name="zipcode" class="zipcode form-control" placeholder="" />
<span class="floating-label">Zipcode</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="tel" name="mobile" class="mobile form-control col-md-8" placeholder="" />
<span class="floating-label">Mobile Phone</span>
<label class="display-flex col-md-4 allow_sms_label">Allow SMS <input type="checkbox" class="allow_sms ml-1" name="allow_sms" value="1"></label>
</div>
<div class="form-group col-md-6 col-12">
<input type="tel" name="mobile2" class="mobile2 form-control" placeholder="" />
<span class="floating-label">Alternate Phone</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12">
<input type="email" name="email" class="email form-control" placeholder="" />
<span class="floating-label">E-mail</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="prefered_lang" class="prefered_lang form-control" placeholder="" />
<span class="floating-label">Preferred Language (if not English)</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12">
<label class="text-label">Best time to reach me</label>
<div class="display-flex">
<label class="display-flex mr-2 time_to_reach"><input type="checkbox" class="time_to_reach_morning mr-1" name="time_to_reach_morning" value="morning">Morning</label>
<label class="display-flex mr-2 time_to_reach"><input type="checkbox" class="time_to_reach_morning mr-1" name="time_to_reach_morning" value="morning">Afternoon</label>
<label class="display-flex mr-2 time_to_reach"><input type="checkbox" class="time_to_reach_morning mr-1" name="time_to_reach_morning" value="morning">Evening</label>
</div>
</div>
<div class="form-group col-md-6 col-12">
<label class="text-label">U.S./Puerto Rico/Guam/U.S.V.I. Resident</label>
<div class="display-flex">
<div class="radio">
<label><input type="radio" name="patient[resident]" class="patresidentr" id="checkbox3" value="Y">Yes</label>
</div>
<div class="radio">
<label><input type="radio" name="patient[resident]" class="patresident" id="checkbox3" value="N">No</label>
</div>
</div>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="cname" class="cname form-control" placeholder="" />
<span class="floating-label">Caregiver Name</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="cphone" class="cphone form-control" placeholder="" />
<span class="floating-label">Caregiver Phone</span>
</div>
</div>
</div> <input type="button" name="next" class="next action-button" value="Next Step" />
</fieldset>
<fieldset>
<div class="form-card">
<h2 class="fs-title insurance_info_title display-flex">PATIENT INSURANCE INFORMATION
<span class="display-flex col-md-6 col-12 p-0">
<label class="display-flex mr-2 col-md-4 col-12 p-0 insurance_info"><input type="checkbox" class="insurance_info_no_inc mr-1" name="insurance_info_no_inc" value="No Insurance">NO INSURANCE</label>
<label class="display-flex mr-2 col-md-6 col-12 p-0 insurance_info"><input type="checkbox" class="insurance_info_sec mr-1" name="insurance_info_sec" value="insurance_info_sec">ADD SECONDARY INSURANCE</label>
</span>
</h2>
<div class="box primary_insurance_box">
<div class="box-header"> PRIMARY INSURANCE</div>
<div class="box-body">
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Primary Insurance Name</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Primary Insurance Payer ID</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Patient Medical Policy ID</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Patient Medical Group ID</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Rx BIN</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Rx PCN</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Rx Group ID</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Rx Policy ID</span>
</div>
</div>
</div>
</div>
<div class="box primary_insurance_box d-none">
<div class="box-header"> Secondary INSURANCE</div>
<div class="box-body">
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Primary Insurance Name</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Rx Policy ID</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Patient Medical Policy ID</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Patient Medical Group ID</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Rx BIN</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Rx PCN</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Rx Group ID</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Rx Policy ID</span>
</div>
</div>
</div>
</div>
</div> <input type="button" name="previous" class="previous action-button-previous" value="Previous" /> <input type="button" name="next" class="next action-button" value="Next Step" />
</fieldset>
<fieldset>
<div class="form-card">
<div class="healthcare_header display-flex">
<h2 class="fs-title insurance_info_title display-flex col-md-6 col-12 p-0">HEALTHCARE PROVIDER INFORMATION</h2>
<div class="display-flex col-md-5 col-12 p-0 search_form">
<label class="text-label">SEARCH PRESCRIBER BY NPI</label>
<div class="display-flex search_field ml-2">
<input type="text" class="insurance_info_no_inc mr-1" name="insurance_info_no_inc" value="">
<button type="submit" class="btn btn-sm btn-primary">Search</button>
</div>
</div>
</div>
<div class="healthcare_header-body">
<div class="display-flex">
<div class="form-group col-md-4 col-12 display-flex">
<input type="text" name="pfname" class="pfname form-control" placeholder="" />
<span class="floating-label">Prescriber First Name</span>
</div>
<div class="form-group col-md-4 col-12">
<input type="text" name="pmname" class="pmname form-control" placeholder="" />
<span class="floating-label">Prescriber Middle Name</span>
</div>
<div class="form-group col-md-4 col-12">
<input type="text" name="plname" class="plname form-control" placeholder="" />
<span class="floating-label">Prescriber Last Name</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Taxonomy</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">State License Number</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Prescriber NPI</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Prescriber Phone Number</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Prescriber Email</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Practice Name</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Practice NPI</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Address Line 1</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Address Line 2</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-4 col-12">
<input type="text" name="city" class="city form-control" placeholder="" />
<span class="floating-label">City</span>
</div>
<div class="form-group col-md-4 col-12">
<select class="list-dt form-control selectbox state" id="patient_state" name="patient[state]">
<option value=""></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
<span class="floating-label">State</span>
</div>
<div class="form-group col-md-4 col-12">
<input type="text" name="zipcode" class="zipcode form-control" placeholder="" />
<span class="floating-label">Zipcode</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Contact Person Name</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Contact Person Phone Number</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Contact Person Email</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Fax Number</span>
</div>
</div>
</div>
</div> <input type="button" name="previous" class="previous action-button-previous" value="Previous" /> <input type="button" name="next" class="next action-button" value="Next Step" />
</fieldset>
<fieldset>
<div class="form-card">
<div class="box primary_insurance_box clinical_box">
<div class="box-header display-flex text-white"> CLINICAL INFORMATION (To be completed by the healthcare provider)</div>
<div class="box-body">
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Primary Diagnosis (ICD-10)</span>
</div>
<div class="form-group col-md-6 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Secondary Diagnosis (ICD-10)</span>
</div>
</div>
<p class="col-md-12 col-12">YOU MAY ATTACH ANY ADDITIONAL CLINICAL NOTES ALONG WITH THIS FORM.</p>
</div>
</div>
<div class="box primary_insurance_box prescription_box">
<div class="box-header text-white"> PRESCRIPTION INFORMATION</div>
<div class="box-body">
<div class="display-flex">
<div class="form-group col-md-10 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Drug Name</span>
</div>
<div class="form-group col-md-2 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Refills</span>
</div>
</div>
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">SIG</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Quantity</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Days Supply</span>
</div>
</div>
<div class="form-group col-md-12 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Notes to Pharmacy</span>
</div>
<div class="form-group col-md-12 col-12 display-flex">
<div class="form-group col-md-3 col-12 p-0">
<label class="display-flex allow_sms_label">Add Bridge Prescription <input type="checkbox" class="allow_sms ml-1" name="allow_sms" value="1"></label>
</div>
<div class="form-group col-md-9 col-12 p-0">
<input type="text" name="mobile" class="mobile form-control" placeholder="" />
<span class="floating-label">Notes to Bridge Pharmacy</span>
</div>
</div>
<p class="col-md-12 col-12">If eligible, prescription may be provided at no cost if a delay occurs in the coverage determination process. For commercially insured patients only (not available for Medicare, Medicaid, or other federal or state healthcare programs).</p>
</div>
</div>
<div class="box primary_insurance_box">
<div class="box-header text-white"> PHARMACY INFORMATION (For electronic prescribing only)</div>
<div class="box-body">
<div class="display-flex">
<div class="form-group col-md-6 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Pharmacy Name</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Pharmacy NPI</span>
</div>
<div class="form-group col-md-3 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Pharmacy NCPDP ID</span>
</div>
</div>
<div class="form-group col-md-12 col-12 display-flex">
<input type="text" name="piname" class="piname form-control" placeholder="" />
<span class="floating-label">Pharmacy Address</span>
</div>
<div class="form-group col-md-12 col-12">
<input type="text" name="pipd" class="pipd form-control" placeholder="" />
<span class="floating-label">Bridge Pharmacy</span>
</div>
<p class="col-md-12 col-12">The patient identified above prefers use of the pharmacy indicated above. I authorize Drug Name and its affiliates, agents, representatives, and service providers to fax this prescription to the pharmacy designated above, provided it is approved by this patient’s plan. If the pharmacy designated is not a plan-approved pharmacy, then to a pharmacy approved by this patient’s plan. If there is no preferred pharmacy indicated, then to any pharmacy approved by this patient’s plan.</p>
</div>
</div>
</div> <input type="button" name="previous" class="previous action-button-previous" value="Previous" /> <input type="button" name="make_payment" class="next submit action-button" value="Submit" />
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<div class="form-card">
<h2 class="fs-title text-center">Success !</h2> <br><br>
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<div class="row justify-content-center">
<div class="col-7 text-center">
<h5>Form Successfully Submitted</h5>
</div>
</div>
</div>
</fieldset>
</form>
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