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<!DOCTYPE html>
<!--
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<html>
<head>
<title>ePA Initiate</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 initiate" 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="col-md-12 mt-4 text-center float-left ">
<h1 class="mt-4 ">ePA Initiate Form</h1>
</div>
<div class="form-card card px-0 pb-0 mb-3">
<!-- Site wrapper -->
<div class="wrapper" id="ajaxPageHolder"><!-- Left side column. contains the logo and sidebar -->
<div class="col-md-12 patient_details display-flex justify-content-space-between pt-2 pb-1 mb-3">
<div class="col-md-4 mb-1 logo-top">
<div class="logo float-right"><img src="images/logo_generic.png" width="210"></div>
</div>
<div class="col-md-4 text-left">
<p><strong>Patient Details:</strong><br>
36 years old, M, Talofofo, GU Maki, Deke</p>
</div>
<div class="col-md-4 text-left">
<p><strong>Pharmacy: </strong>Pharmacy Benefit PA <br>
<strong>Drug Name: </strong>Xolair 150 mg vial</p>
</div>
<div class="col-md-4 mb-1 logo-bottom">
<div class="logo float-right"><img src="images/logo_generic.png" width="210"></div>
</div>
</div>
</div>
<!--<script type="text/javascript" src="https://qaspnrx.evincemed.net/assets/check_browser_tab_close.js"></script>-->
<section class="content pb-4">
<div class="box box-default">
<!-- /.box-header -->
<form method="post" id="epaInitiateForm">
<input type="hidden" name="ref_id" value="729C8338BECDA6E7A262CCAE28FF815D">
<input type="hidden" name="auth_username" value="amgen">
<input type="hidden" name="sso_userID" value="devuser">
<input type="hidden" name="EMID" value="22150">
<input type="hidden" name="Urgent" value="">
<input type="hidden" name="PayerID" value="T00000000023152">
<input type="hidden" name="PayerName" value="Pruebas PBM">
<input type="hidden" name="GroupName" value="GUAM-2">
<input type="hidden" name="EligibilityMessageID" value="9999999">
<input type="hidden" name="PatientFirstName" value="Deke">
<input type="hidden" name="PatientLastName" value="Maki">
<input type="hidden" name="PatientMiddleName" value="James">
<input type="hidden" name="PatientSuffix" value="">
<input type="hidden" name="PatientGender" value="M">
<input type="hidden" name="PatientDob" value="1985-08-11">
<input type="hidden" name="PatientAddressLine1" value="11 Talofofo Road">
<input type="hidden" name="PatientAddressLine2" value="4A">
<input type="hidden" name="PatientCity" value="Talofofo">
<input type="hidden" name="PatientState" value="GU">
<input type="hidden" name="PatientZip" value="969150000">
<input type="hidden" name="PatientPhone" value="9685968500">
<input type="hidden" name="ProviderNPI" value="1518961887">
<input type="hidden" name="PrescriberLastName" value="PICCIONE">
<input type="hidden" name="PrescriberFirstName" value="FRANCIS">
<input type="hidden" name="PrescriberAddressLine1" value="718 SMYTH RD">
<input type="hidden" name="PrescriberAddressLine2" value="">
<input type="hidden" name="PrescriberCity" value="MANCHESTER">
<input type="hidden" name="PrescriberState" value="NH">
<input type="hidden" name="PrescriberZip" value="031047007">
<input type="hidden" name="PrescriberPhone" value="6036244366">
<input type="hidden" name="PrescriberFax" value="6030304304">
<input type="hidden" name="UserType" value="Prescriber">
<input type="hidden" name="UserID" value="devuser">
<input type="hidden" name="UserLastName" value="User">
<input type="hidden" name="UserFirstName" value="Test">
<input type="hidden" name="UserPhoneNo" value="9999999999">
<input type="hidden" name="UserFaxNo" value="7034145557">
<div class="box-body">
<div class="col-md-12">
<div class="display-flex row align-center">
<div class="col-md-4 col-12 form-group">
<label for="PAReferenceID">PA Reference ID<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval" required value="89898989" name="PAReferenceID" id="PAReferenceID" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="orderingPrescriber">Ordering /Prescribing Physician<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval" required value="PICCIONE, FRANCIS - 1518961887" name="orderingPrescriber" id="orderingPrescriber" placeholder="">
</div>
<div class="col-md-4 col-12 text-left physician_info">
<div class="pinfo_box">
<label class="px-2 py-1">Physician Information</label>
<p class="px-2"><strong>NPI: </strong>1518961887</p>
<p class="px-2"><strong>Address: </strong>718 SMYTH RD</p>
<p class="px-2"><strong>City/State/Zip: </strong>MANCHESTER, NH, 031047007</p>
<p class="px-2"><strong>Phone: </strong>6036244366</p>
<p class="px-2"><strong>Fax: </strong>6030304304</p>
</div>
</div>
</div>
<!-- /.row -->
<div class="row">
<input type="hidden" name="DrugDescription" value="Xolair 150 mg vial">
<input type="hidden" name="DrugNDC" value="50242004062">
<div class="col-md-12 mt-3"></div>
<div class="col-md-4 col-12 form-group">
<label for="drugSigText">Sig.<sup style="color: red;">*</sup> <small>max 140 characters</small></label>
<input type="text" class="form-control requiredval" value="Inject 225 mg subcutaneously once every 2 weeks" name="DrugSigText" required id="drugSigText" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="bin">Bin no</label>
<input type="text" class="form-control requiredval numval" maxlength="6" value="004951" name="BIN" required id="bin" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="drugPackageRefills">Package Unit <small>optional</small></label>
<input type="text" class="form-control" value="C64933" name="DrugQuantityUnitOfMeasure" id="DrugQuantityUnitOfMeasure" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="pbmMemberId">PBM Member ID</label>
<input type="text" class="form-control requiredval numval" value="PBS$GU923312-51R211" name="PBMMemberID" required id="pbmMemberId" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="drugQuantity">Quantity<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="6" name="DrugQuantity" required id="drugQuantity" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="pbmMemberId">Card Holder ID</label>
<input type="text" class="form-control requiredval" value="GU2-MAKID" name="CardHolderID" required id="CardHolderID" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="drugDaysSupply">Supply<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="60" name="DrugDaysSupply" required id="drugDaysSupply" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="pcn">PCN</label>
<input type="text" class="form-control numval" value="4951-GU2" name="PCN" id="pcn" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="commercial_drugNumberOfRefills">Refills</label>
<input type="text" class="form-control numval" value="1" name="DrugNumberOfRefills" id="drugNumberOfRefills" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="group_id">Group ID</label>
<input type="text" class="form-control" value="GP-GU2" name="GroupID" id="group_id" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="PrimaryICDCode">Primary Diagnosis Code</label>
<input type="text" class="form-control" value="J4540" name="PrimaryICDCode" id="PrimaryICDCode" placeholder="">
</div>
<div class="col-md-4 col-12 form-group">
<label for="SecondaryICDCode">Secondary Diagnosis Code</label>
<input type="text" class="form-control" value="" name="SecondaryICDCode" id="SecondaryICDCode" placeholder="">
</div>
</div>
</div>
<div class="clearfix"></div>
<center><button type="button" id="sub_btn" class="btn btn-block btn-danger btn-lg mt-4" style="width: 300px;">Submit Prior Authorization</button></center>
</div>
<!-- /.box-body -->
</form>
</div>
</section>
</div>
</div>
</div>
</div>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/js/bootstrap.bundle.min.js"></script>
<script src="js/custom.js"></script>
</body>
</html>