| Linux server27.hostingraja.org 2.6.32-954.3.5.lve1.4.93.el6.x86_64 #1 SMP Wed Oct 4 17:04:29 UTC 2023 x86_64 Path : /home/udaipurk/public_html/websites/tezspire/resources/views/ |
| Current File : /home/udaipurk/public_html/websites/tezspire/resources/views/tez.blade.php |
<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title><?php echo $title ?? "Tezspire Together | Program Enrollment Form"; ?></title>
<?php
$base_url = "https://www.pfizer.com/";
$saved_data = old();
// print_r(old()); die();
?>
<!-- Favicon -->
<link rel="shortcut icon" href="<?php echo $base_url; ?>assets/forms/xelsource/favicon.png" type="image/x-icon">
<link rel="icon" href="<?php echo $base_url; ?>assets/forms/xelsource/favicon.png" type="image/x-icon">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap@5.1.3/dist/css/bootstrap.min.css" crossorigin="anonymous">
<link rel="stylesheet" href="https://cdn.datatables.net/1.11.3/css/jquery.dataTables.min.css" crossorigin="anonymous">
<link rel="preconnect" href="https://fonts.googleapis.com">
<link rel="preconnect" href="https://fonts.gstatic.com" crossorigin>
<link href="https://fonts.googleapis.com/css2?family=Open+Sans:ital,wght@0,300;0,400;0,600;0,700;0,800;1,500&family=Poppins:wght@300;400;500;600;700;800;900&display=swap" rel="stylesheet">
<script src="https://code.jquery.com/jquery-3.6.0.min.js"></script>
<script src="https://code.jquery.com/ui/1.13.0/jquery-ui.min.js" integrity="sha256-hlKLmzaRlE8SCJC1Kw8zoUbU8BxA+8kR3gseuKfMjxA=" crossorigin="anonymous"></script>
<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.1.3/dist/js/bootstrap.min.js" crossorigin="anonymous"></script>
<script src="https://cdn.datatables.net/1.11.3/js/jquery.dataTables.min.js" crossorigin="anonymous"></script>
<!-- Ajax -->
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.14.7/umd/popper.min.js" integrity="sha384-UO2eT0CpHqdSJQ6hJty5KVphtPhzWj9WO1clHTMGa3JDZwrnQq4sF86dIHNDz0W1" crossorigin="anonymous"></script>
<!-- Signature Pad -->
<script src="https://cdn.jsdelivr.net/npm/signature_pad@2.3.2/dist/signature_pad.min.js"></script>
<!--<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.1.3/dist/js/bootstrap.bundle.min.js" crossorigin="anonymous"></script>-->
<style type="text/css">
body {
font-family: Open Sans;
margin-left: 0px;
margin-top: 0px;
margin-right: 0px;
margin-bottom: 0px;
background-color: #ffffff;
}
#popup2{
display: none;
}
.shadow {
padding: 0px 0px 0px 0px;
border: 1px solid #BFBFBF;
background-color: white;
box-shadow: 0px 0px 5px #aaaaaa;
}
.txt1 {font-size:15px; font-weight:bold; font-family:"Poppins";}
.txt2 {font-size:14px; font-family:"Open Sans";}
.txt3 {font-size:16px; font-family:"Open Sans"; font-weight:bold;}
.txt4 {font-size:27px; font-weight:normal; font-family:"Poppins"; color:#e40571;}
.txt5 {font-size:11px; font-weight:normal; font-family:"Open Sans";}
.txt6 {font-size:11px; font-weight:normal; font-family:"Open Sans"; color: #862665;}
.txt7 {font-size:20px; font-family:"Open Sans"; font-weight:bold; color:#FFFFFF;}
.txt8 {font-size:20px; font-family:"Open Sans"; font-weight:bold; color:#862665; line-height: 1;}
.txt9 {font-size:24px; font-family:"Open Sans"; font-weight:bold; color:#e40571;}
.txt10 {font-size:16px; font-weight:normal; font-family:"Open Sans"; color:#6d6e71;}
.txt11 {font-size:18px; font-weight:bold; font-family:"Open Sans"; color:#6d6e71;}
.txt13 {font-size:13px;}
.txt12 {font-size:12px;}
.brd1 {border-bottom: 1px solid #c6c8ca;}
.brd2 {border: 1px solid #862665;}
input {font-family:"Open Sans"; font-size:14px; }
body input:focus {border-color: #ced4da !important; box-shadow: none !important;}
.uinput {font-family:"Open Sans"; font-size:14px; color:#e40571;}
a:link {color: #0063a8; font-size:13px; text-decoration:underline;}
a:hover {color: #862466;}
.button1 { background-color: #39b04a; /* Green */
border: none;
color: white;
padding: 15px 25px 15px 25px;
text-align: center;
text-decoration: none;
display: inline-block;
font-size: 18px;
border-radius: 4px;
font-weight:bold;
font-family:"";
}
.button2 { background-color: #39b04a; /* Green */
border: none;
color: white;
padding: 5px 10px 5px 10px;
text-align: center;
text-decoration: none;
display: inline-block;
font-size: 14px;
border-radius: 4px;
font-family:"";
}
.instruction_msg_section{
background-color: #ebebeb;
}
.bg-yellow{
background: #ffc600;
}
.bg-pink{
background: #ef426f;
}
.bg-orange{
background: #ff7f32;
}
.bg-purple{
background: #003865;
}
.text-yellow{
color: #ffc600;
}
.text-pink{
color: #ef426f;
}
.text-orange{
color: #ff7f32;
}
.text-purple{
color: #003865;
}
.text-bold{
font-weight: bold;
}
.title_image img{
height: 30px;
max-width: 100%;
}
.one_line{
padding: 5px 0;
}
.pat-sign-img{
height: 40px;
}
img{
max-width: 100%;
}
.prescriber_certification_form .px-3{
padding-left: 1.3rem!important;
}
.align-self-normal{
align-self: normal;
}
.align-self-normal .px-3{
align-self: flex-end;
}
.ng-mt-3{
margin-top: -3px;
}
.prescriber_certification_form .prescriber_certification{
/*border: 1px solid #000;*/
padding: 5px;
}
.other_rx_block .brd11, .other_rx_block .brd11 .uinput{
width: 98%;
}
.other_rx_refills{
width: 160px;
}
.footer_logo_img{
height: 40px;
}
.footer_logo_img2{
height: 30px;
}
.mt-150{
margin-top: 150px;
}
.form-group{
position: relative;
padding: 10px;
}
.text-label{
top: 0;
left: 0;
font-size: 14px;
padding: 0px 5px;
position: absolute;
transform: translate(14px, 12px) scale(1);
color: rgba(0, 0, 0, 0.54);
font-weight: 400;
line-height: 2.5;
letter-spacing: 0.00938em;
position: absolute;
z-index: 9;
}
.mobile_phone_yes{
padding: 18px 10px;
}
.date_field .text-label{
top: -8px !important;
left: -5px !important;
line-height: 1;
font-size: 11px;
background: #ffffff;
padding: 0 5px;
}
.section_one, .section_two, .section_three, .section_four, .section_five, .section_six, .section_seven, .section_eight, .section_nine{
border: 1px solid #ff7f32;
border-radius: 10px;
padding: 5px;
margin-bottom: 30px;
}
.signature_div{
width: 100%;
}
.signature_div div.mb-1{
cursor: pointer;
display: flex;
background: #FDE0E0 0% 0% no-repeat padding-box;
align-items: center;
border-radius: 4px;
justify-content: center;
padding: 9px 30px;
}
.other_diagnosis_label{
width: 150px;
}
#other_diagnosis_text, #allergies_text, #spc_pharmacy_text, #icd_code_other_text, #other_rx_refill_text, #certification_other_rx_text, #pharmacy_link{
display: none;
}
.diagnosis_code_category{
min-height: 38px;
}
.other_rx_block{
min-height: 68px;
}
.or_block{
display: flex !important;
justify-content: space-evenly !important;
align-items: center;
border-top: 1px solid #ccc;
position: relative;
}
.or_block span{
width: 40px;
height: 40px;
text-align: center;
padding: 1%;
border-radius: 50%;
background: gray;
color: #fff;
font-weight: 600;
position: absolute;
top: -20px;
}
.prescriber_certification #quantity_dispensed_text strong{
width: 260px;
}
.text-right{
text-align: right;
}
.text-bold{
font-weight: bold !important;
}
.text-dark{
color: #000 !important;
}
.section_nine a{
font-size: 18px;
font-weight: bold;
font-family: "Open Sans";
}
.section_nine a:hover{
color: #862466;
}
.modal .btn-primary:active, .modal .btn-primary:hover{
background-color: #862466;
}
#pharmacyModal .modal-dialog{
max-width: 80%;
}
#pharmacyTable .paginate_button{
padding: 3px 11px;
}
#pharmacyTable tbody tr{
cursor: pointer;
}
.section_three .no_insurance label{
color: #fff;
border: 1px solid #ef426f;
font-size: 15px;
margin-top: 5px;
padding: 5px 10px;
border-radius: 5px;
cursor: pointer;
background: #ef426f;
}
.npi_provider input{
border-bottom-right-radius: 0;
border-top-right-radius: 0;
}
.npi_provider button{
border-bottom-left-radius: 0;
border-top-left-radius: 0;
}
#form2{
width: 100%;
}
.header_no{
padding: 2px 12px;
color: #fff;
font-size: 20px;
border-top-left-radius: 10px;
border-bottom-right-radius: 10px;
margin-right: 10px;
}
.title_image {
margin: -5px 0 0 -5px;
}
.title_image .header-title{
font-size: 22px;
font-weight: 700;
padding-top: 8px;
}
div, p, span{
color: #003865;
}
strong{
font-weight: bold;
}
.height-58{
height: 58px;
}
.patient_insurance_form h4{
margin-bottom: 0;
font-size: 18px;
}
.note_section{
margin: 0 auto;
background: #f7f7f7;
font-size: 24px;
margin-top: 30px;
margin-bottom: 60px;
border-top: 3px solid orange;
border-bottom: 2px solid orange;
box-shadow: 0px 2px 6px #aaaaaa;
}
.program_service_form .txt-11{
font-size: 15px;
line-height: 25px;
}
.program_service_form .txt-11 input[type=checkbox], .clinical_information_form .icd_code_section input[type=checkbox] {
/* width: auto;
height: 16px;*/
margin-top: 5px;
}
.clinical_information_form .input-group>.form-control, .section-four .input-group>.form-select {
position: initial;
}
.br1{
width: 1px;
padding: 40px 1px;
background: #003865;
}
.pl-1{
padding-left: 0.5rem;
}
.pr-2{
padding-right: 1rem;
}
.pl-3{
padding-left: 1.5rem;
}
.footer_logo_img.amgen_logo{
height: 20px;
margin-right: 30px;
}
.mb-1{
font-size:16px;
}
.signature_div .content {
position: relative;
width: 400px;
height: 200px;
-moz-user-select: none;
-webkit-user-select: none;
-ms-user-select: none;
user-select: none;
}
.signature-pad {
position: absolute;
left: 0;
top: 0;
width:400px;
height:200px;
}
@media (min-width: 1200px){
.container, .container-lg, .container-md, .container-sm, .container-xl {
max-width: 1040px;
}
}
@media screen and (min-width: 768px) {
.no_refills{
padding-left: 60px;
}
.no_refills_sign{
padding-left: 20px;
}
.clinical_information_form .input-group{
width: 50%;
}
.header .txt4{
font-size: 30px;
}
}
@media screen and (max-width: 580px) {
.d-flex {
display: block !important;
}
.header img{
margin-bottom: 10px;
width: 100%;
height: auto;
}
.txt4 {
font-size: 22px;
}
.d-flex-mobile{
display: flex !important;
}
.or_block{
display: flex !important;
justify-content: space-evenly !important;
align-items: center;
border-top: 1px solid #ccc;
position: relative;
}
.or_img_block{
padding: 30px;
}
.or_img_block img{
display: none;
}
.or_block span{
width: 40px;
height: 40px;
text-align: center;
padding: 4% 1%;
border-radius: 50%;
background: gray;
color: #fff;
font-weight: 600;
position: absolute;
top: -20px;
}
.section_footer_logo{
text-align: center;
}
.signature_div div{
margin-left: 0;
margin-top: 10px;
}
.allergies_field{
padding-right: .5rem;
padding-left: .5rem;
}
.start_program_form{
padding-bottom: 40px !important;
}
.start_program_form .no_refills_sign input{
width: 100%;
float: left;
}
.mtext-center{
text-align: center;
}
.title_image {
margin: 0;
}
.header_no{
margin-right: 0;
width: 100%;
border-bottom-right-radius: 0;
border-top-right-radius: 10px;
text-align: center;
}
.section_one, .section_two, .section_three, .section_four, .section_five, .section_six, .section_seven, .section_eight, .section_nine{
padding: 0;
}
.title_image .header-title{
text-align: center;
}
.height-58{
height: auto;
}
.one_line {
padding: 0;
}
.patient_auth_text{
padding: 0 10px;
}
.pat-sign-img{
display: none;
}
.pat_sig_box{
margin-bottom: 10px;
}
.patient_sign_section .px-2{
padding-left: 0 !important;
padding-right: 0 !important;
}
.mp-10{
padding: 10px;
}
.note_section {
font-size: 16px;
margin-bottom: 30px;
}
.primary_diag_code .d-flex-mobile{
width: 100% !important;
}
.prec_info_sub_text{
width: 100%;
float: left;
}
.prescriber_certification_form .px-3.sig_section{
padding: 0 !important;
margin-top: 10px;
}
.sig_section .refill_section{
margin-top: 10px;
}
.dispense_written .px-2{
padding-left: 0 !important;
padding-right: 0 !important;
}
.br1{
width: 100%;
padding: 1px;
margin: 10px 0;
}
.title_image .header-title{
line-height: 1;
}
.tezspire_form.px-4{
padding-right: 1rem!important;
padding-left: 1rem!important;
}
input[type=checkbox]{
margin-top: 5px;
outline-color: #ff7f32;
}
.no_insurance{
text-align: center;
}
.text-label {
top: 10px;
font-size: 11px !important;
line-height: 1 !important;
position: absolute;
max-width: 91%;
}
}
</style>
</head>
<body>
<div class="container">
<div class="row">
<div class="tezspire_form px-4 pt-4 bg-white">
@if($errors->any())
@foreach ($errors->all() as $error)
<div class="alert alert-danger p-1 mb-2">{{ $error }}</div>
@endforeach
@endif
@foreach (['danger', 'warning', 'success', 'info'] as $msg)
@if(Session::has('alert-' . $msg))
<p class="alert alert-{{ $msg }}">{{ Session::get('alert-' . $msg) }} <a href="#" class="close" data-dismiss="alert" aria-label="close">×</a></p>
@endif
@endforeach
<form id="enroll_form" name="form1" method="post">
<input type="hidden" name="ref_id" id="ref_id" value="<?php echo $ref_id ?? ""; ?>" />
<input type="hidden" name="pdfFormString" id="pdfFormString" value="" />
<input type="hidden" name="form_url" id="form_url" value="<?php echo $form_url ?? ""; ?>" />
<input type="hidden" name="form_id" id="form_id" value="<?php echo $form_id ?? ""; ?>" />
<input type="hidden" name="form_template_name" id="form_template_name" value="<?php echo $form_template_name ?? ""; ?>" />
<div class="header d-flex mb-2 col-md-12 col-12 align-items-center justify-content-space-between">
<div class="col-md-4">
<img src="images/logo.png" alt="">
</div>
<div class="col-md-6 text-bold text-right">
<div class="txt4 text-purple mtext-center"><strong>Program Enrollment Form</strong></div>
</div>
</div>
<div class="ad_assist_msg_section d-flex col-md-12 col-12 p-1 justify-content-between align-items-center">
<div class="ad_assist_msg txt12 text-purple mtext-center">Note: Section 1 to be completed and signed by the patient or legal representative.</div>
<div class="ad_assist_msg txt5 text-purple mtext-center">An asterisk (*) indicates a required field.</div>
</div>
<div class="section_one col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-12 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">1</div>
<div class="d-flex ml-2 col-md-5 col-sm-11 col-12 header-title txt-8 text-pink">PATIENT INFORMATION</div>
<div class="d-flex d-flex-mobile justify-content-end align-items-center col-md-6 col-sm-12 col-12 form-group height-58">
<strong>Sex Assigned at Birth:*</strong>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="patGender gender" type="checkbox" name="patient[gender]" id="checkbox3" checked value="M" <?php echo!empty($saved_data['patient']['gender']) && $saved_data['patient']['gender'] == 'M' ? "checked" : "" ?>>
<label>Male</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="patGender gender" type="checkbox" name="patient[gender]" id="checkbox3" value="F" <?php echo!empty($saved_data['patient']['gender']) && $saved_data['patient']['gender'] == 'F' ? "checked" : "" ?>>
<label>Female</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="patGender gender" type="checkbox" name="patient[gender]" id="checkbox3" value="O" <?php echo!empty($saved_data['patient']['gender']) && $saved_data['patient']['gender'] == 'O' ? "checked" : "" ?>>
<label>Other</label>
</div>
</div>
</div>
<!-- <div class="d-flex justify-content-end align-items-center col-md-6 col-sm-12 col-12 form-group">
<strong>Sex Assigned at Birth:*</strong>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="gender" type="checkbox" name="checkbox4" id="checkbox3">
<label>Male</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="gender" type="checkbox" name="checkbox4" id="checkbox3">
<label>Female</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="gender" type="checkbox" name="checkbox4" id="checkbox3">
<label>Not Specified</label>
</div>
</div>-->
</div>
<div class="patient_form d-flex flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-start">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">First Name:* </label>
<input class="form-control" required type="text" id="patient_fname" name="patient[fname]" value="<?php echo!empty($saved_data['patient']['fname']) ? $saved_data['patient']['fname'] : "" ?>">
{{csrf_field()}}
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">Last Name:* </label>
<input class="form-control" required type="text" id="patient_lname" name="patient[lname]" value="<?php echo!empty($saved_data['patient']['lname']) ? $saved_data['patient']['lname'] : "" ?>">
</div>
<div class="d-flex justify-content-start align-items-center col-md-4 col-sm-12 col-12 form-group flex-column date_field">
<label class="text-label">Date Of Birth:* </label>
<input class="form-control date_input" required type="date" id="patient_dob" name="patient[dob]" value="<?php echo!empty($saved_data['patient']['dob']) ? $saved_data['patient']['dob'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-start">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">Address Line 1:* </label>
<input class="form-control" name="patient[address]" type="text" id="patient_address1" value="<?php echo!empty($saved_data['patient']['address']) ? $saved_data['patient']['address'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">Address Line 2: </label>
<input class="form-control" name="patient[address2]" type="text" id="patient_address2" value="<?php echo!empty($saved_data['patient']['address2']) ? $saved_data['patient']['address2'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">City:* </label>
<input class="form-control" required type="text" id="patient_city" name="patient[city]" value="<?php echo!empty($saved_data['patient']['city']) ? $saved_data['patient']['city'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-start">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">State:* </label>
<!--<input class="form-control" name="textfield44" type="text" id="textfield50" name="state" value="<?php // echo!empty($saved_data['patient']['state']) ? $saved_data['patient']['state'] : "" ?>">-->
<select name="patient[state]" id="patient_state" class="form-control selectbox" required>
<option value=""></option>
<option value="AL" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'AL')) ? 'selected' : ''; ?>>Alabama</option>
<option value="AK" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'AK')) ? 'selected' : ''; ?>>Alaska</option>
<option value="AZ" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'AZ')) ? 'selected' : ''; ?>>Arizona</option>
<option value="AR" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'AR')) ? 'selected' : ''; ?>>Arkansas</option>
<option value="CA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'CA')) ? 'selected' : ''; ?>>California</option>
<option value="CO" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'CO')) ? 'selected' : ''; ?>>Colorado</option>
<option value="CT" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'CT')) ? 'selected' : ''; ?>>Connecticut</option>
<option value="DE" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'DE')) ? 'selected' : ''; ?>>Delaware</option>
<option value="DC" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'DC')) ? 'selected' : ''; ?>>District Of Columbia</option>
<option value="FL" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'FL')) ? 'selected' : ''; ?>>Florida</option>
<option value="GA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'GA')) ? 'selected' : ''; ?>>Georgia</option>
<option value="HI" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'HI')) ? 'selected' : ''; ?>>Hawaii</option>
<option value="ID" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'ID')) ? 'selected' : ''; ?>>Idaho</option>
<option value="IL" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'IL')) ? 'selected' : ''; ?>>Illinois</option>
<option value="IN" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'IN')) ? 'selected' : ''; ?>>Indiana</option>
<option value="IA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'IA')) ? 'selected' : ''; ?>>Iowa</option>
<option value="KS" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'KS')) ? 'selected' : ''; ?>>Kansas</option>
<option value="KY" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'KY')) ? 'selected' : ''; ?>>Kentucky</option>
<option value="LA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'LA')) ? 'selected' : ''; ?>>Louisiana</option>
<option value="ME" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'ME')) ? 'selected' : ''; ?>>Maine</option>
<option value="MD" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MD')) ? 'selected' : ''; ?>>Maryland</option>
<option value="MA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MA')) ? 'selected' : ''; ?>>Massachusetts</option>
<option value="MI" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MI')) ? 'selected' : ''; ?>>Michigan</option>
<option value="MN" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MN')) ? 'selected' : ''; ?>>Minnesota</option>
<option value="MS" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MS')) ? 'selected' : ''; ?>>Mississippi</option>
<option value="MO" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MO')) ? 'selected' : ''; ?>>Missouri</option>
<option value="MT" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'MT')) ? 'selected' : ''; ?>>Montana</option>
<option value="NE" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NE')) ? 'selected' : ''; ?>>Nebraska</option>
<option value="NV" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NV')) ? 'selected' : ''; ?>>Nevada</option>
<option value="NH" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NH')) ? 'selected' : ''; ?>>New Hampshire</option>
<option value="NJ" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NJ')) ? 'selected' : ''; ?>>New Jersey</option>
<option value="NM" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NM')) ? 'selected' : ''; ?>>New Mexico</option>
<option value="NY" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NY')) ? 'selected' : ''; ?>>New York</option>
<option value="NC" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'NC')) ? 'selected' : ''; ?>>North Carolina</option>
<option value="ND" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'ND')) ? 'selected' : ''; ?>>North Dakota</option>
<option value="OH" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'OH')) ? 'selected' : ''; ?>>Ohio</option>
<option value="OK" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'OK')) ? 'selected' : ''; ?>>Oklahoma</option>
<option value="OR" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'OR')) ? 'selected' : ''; ?>>Oregon</option>
<option value="PA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'PA')) ? 'selected' : ''; ?>>Pennsylvania</option>
<option value="RI" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'RI')) ? 'selected' : ''; ?>>Rhode Island</option>
<option value="SC" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'SC')) ? 'selected' : ''; ?>>South Carolina</option>
<option value="SD" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'SD')) ? 'selected' : ''; ?>>South Dakota</option>
<option value="TN" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'TN')) ? 'selected' : ''; ?>>Tennessee</option>
<option value="TX" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'TX')) ? 'selected' : ''; ?>>Texas</option>
<option value="UT" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'UT')) ? 'selected' : ''; ?>>Utah</option>
<option value="VT" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'VT')) ? 'selected' : ''; ?>>Vermont</option>
<option value="VA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'VA')) ? 'selected' : ''; ?>>Virginia</option>
<option value="WA" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'WA')) ? 'selected' : ''; ?>>Washington</option>
<option value="WV" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'WV')) ? 'selected' : ''; ?>>West Virginia</option>
<option value="WI" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'WI')) ? 'selected' : ''; ?>>Wisconsin</option>
<option value="WY" <?php echo (!empty($saved_data['patient']['state']) && ($saved_data['patient']['state'] == 'WY')) ? 'selected' : ''; ?>>Wyoming</option>
</select>
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column required">
<label class="text-label">ZIP Code:* </label>
<input class="form-control zipval zip_field" required type="text" id="patient_zip" name="patient[zip]" value="<?php echo!empty($saved_data['patient']['zip']) ? $saved_data['patient']['zip'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">Email:* </label>
<input class="form-control emailval" required type="text" id="patient_email" name="patient[email]" value="<?php echo!empty($saved_data['patient']['email']) ? $saved_data['patient']['email'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-start">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group flex-column">
<label class="text-label">Phone:* </label>
<input class="form-control mobval" required type="tel" id="patient_phone" name="patient[phone]" value="<?php echo!empty($saved_data['patient']['phone']) ? $saved_data['patient']['phone'] : "" ?>">
</div>
<div class="d-flex justify-content-start align-items-center px-3 col-md-4 col-sm-12 col-12 form-group height-58">
<input class="phone_type" type="checkbox" name="patient[phone_type]" id="patient_phone_type" value="home" <?php echo!empty($saved_data['patient']['phone_type']) && $saved_data['patient']['phone_type'] == "home" ? "checked" : "" ?>">
Home
<input class="phone_type" type="checkbox" name="patient[phone_type]" id="patient_phone_type" value="mobile" <?php echo!empty($saved_data['patient']['phone_type']) && $saved_data['patient']['phone_type'] == "mobile" ? "checked" : "" ?>">
Mobile
</div>
<div class="d-flex justify-content-start align-items-center col-md-4 col-sm-12 col-12 form-group flex-column height-58">
<div class="d-flex justify-content-start align-items-center px-1 col-md-12 col-sm-12 col-12">
<strong>Preferred Form of Contact: </strong>
</div>
<div class="d-flex justify-content-start align-items-center col-md-12 col-sm-12 col-12">
<div class="d-flex justify-content-start align-items-center px-1">
<input type="checkbox" name="patient[preferred_form_of_contact]" id="patient_preferred_form_of_contact" value="phone" <?php echo!empty($saved_data['patient']['preferred_form_of_contact']) && $saved_data['patient']['preferred_form_of_contact'] == "phone" ? "checked" : "" ?>">
<label>Phone</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input type="checkbox" name="patient[preferred_form_of_contact]" id="patient_preferred_form_of_contact" value="text" <?php echo!empty($saved_data['patient']['preferred_form_of_contact']) && $saved_data['patient']['preferred_form_of_contact'] == "text" ? "checked" : "" ?>">
<label>Text</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input type="checkbox" name="patient[preferred_form_of_contact]" id="patient_preferred_form_of_contact" value="email" <?php echo!empty($saved_data['patient']['preferred_form_of_contact']) && $saved_data['patient']['preferred_form_of_contact'] == "email" ? "checked" : "" ?>">
<label>Email</label>
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center flex-column">
<div class="d-flex justify-content-start align-items-center px-1 col-md-12 col-sm-12 col-12 form-group height-58">
<div class="d-flex justify-content-start align-items-center col-md-6 px-2 col-sm-12 col-12 form-group height-58">
<strong>Best Time to Contact: </strong>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="prefer_contact" type="checkbox" name="patient[best_time_to_reach]" id="checkbox25" value="morning" <?php echo!empty($saved_data['patient']['best_time_to_reach']) && $saved_data['patient']['best_time_to_reach'] == "morning" ? "checked" : "" ?>">
<label>Morning</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="prefer_contact" type="checkbox" name="patient[best_time_to_reach]" id="checkbox25" value="afternoon" <?php echo!empty($saved_data['patient']['best_time_to_reach']) && $saved_data['patient']['best_time_to_reach'] == "afternoon" ? "checked" : "" ?>">
<label>Afternoon</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="prefer_contact" type="checkbox" name="patient[best_time_to_reach]" id="checkbox25" value="evening" <?php echo!empty($saved_data['patient']['best_time_to_reach']) && $saved_data['patient']['best_time_to_reach'] == "evening" ? "checked" : "" ?>">
<label>Evening</label>
</div>
</div>
<div class="d-flex justify-content-start align-items-center col-md-6 col-sm-12 col-12 form-group">
<label class="text-label">Preferred Language (if not English): </label>
<input class="form-control" name="patient[language]" type="text" id="patient_language" value="<?php echo!empty($saved_data['patient']['language']) ? $saved_data['patient']['language'] : "" ?>">
</div>
</div>
</div>
</div>
<div class="one_line patient_auth_text col-md-12 col-sm-12 col-12 d-flex form-group justify-content-start flex-column align-items-center">
<div class="d-flex justify-content-start col-12 txt-11 text-purple text-uppercase">
<strong>Patient Authorization</strong>
</div>
<div class="d-flex justify-content-start col-12 txt-11">
Legal representative is required if patient is younger than 18 years of age.
</div>
<div class="d-flex justify-content-start col-12 txt-11">
I have read and agree to the Authorization to Use and Disclose Personal Information mentioned below.
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-flex justify-content-start col-md-8 col-sm-6 col-12 align-items-center form-group">
<img class="pat-sign-img" src="images/arrow.png" alt="">
<div class="d-flex patient_sign_section justify-content-between col-md-12 col-sm-12 col-12 align-items-center">
<div class="d-flex pat_sig_box justify-content-start align-items-center px-2 flex-column">
<label class="text-pink"><strong>Signature of Patient/Legal Representative:*</strong></label>
<div class="signature_div">
<div class="mb-1">
<a class="button" id="click_to_sign" href="#popup1" rel="modal:open">Click here to sign</a>
<div class="patient_commutication_signed signed" style="display: none;">
<div class="sigWrapper">
<a href="#popup1" rel="modal:open"><div class="typed" id="communication_typed"></div></a>
<a href="#popup1" rel="modal:open"><canvas class="pad" id="communication_draw" width="198" height="55"></canvas></a>
</div>
</div>
<input type="hidden" name="patient[signature]" id="patient_commutication_authoriation_signature_name" value="" />
<input type="hidden" name="patient[signature]" id="patient_commutication_authoriation_signImageFile" value="" />
<div id="popup1" class="modal">
<div class="content">
<canvas id="signature-pad" class="signature-pad" width=198 height=55></canvas>
<!-- <div id="sig" style="width:50%; min-heght:50px;height: 235px;">
<div class="patient_commutication_sigPad">
<label for="name" id="print_name">Print your name</label>
<input type="text" name="patient_commutication_authoriation[sign_name]" id="patient_commutication_authoriation_sign_name" class="name data" style="padding-left: 5px;">
<p class="typeItDesc">Review your signature</p>
<p class="drawItDesc">Draw your signature</p>
--> <ul class="sigNav">
<li class="typeIt"><a href="#type-it" class="current">Type It</a></li>
<li class="drawIt"><a id="save" href="#draw-it" >Draw It</a></li>
<li class="clearButton"><a id="clear" href="#clear">Clear</a></li>
</ul><!--
<div class="sig sigWrapper">
<div class="typed"></div>
<canvas class="pad" id="signature-pad-canvas" width="350" height="100"></canvas>
<input type="hidden" name="output" class="output">
</div>
<br />
<input type="button" id="patient_commutication_save" value="Save" />
</div>
</div>-->
<textarea id="patient_signature64" name="patient[signature64]" style="display: none"></textarea>
</div>
</div>
</div>
</div>
</div>
<div class="d-flex pat_name_box justify-content-start align-items-center px-2 flex-column">
<label class="text-pink"><strong>Name of Patient/Legal Representative:*</strong></label>
<input class="form-control" required name="patient[representative_name]" type="text" id="patient_representative_name" value="<?php echo!empty($saved_data['patient']['representative_name']) ? $saved_data['patient']['representative_name'] : "" ?>">
</div>
</div>
</div>
<div class="d-flex justify-content-end col-md-3 col-sm-6 col-12 date_field form-group align-items-center pt-4">
<label>Date: </label>
<input class="form-control date-format local" required name="patient[representative_date]" type="date" id="patient_representative_date" value="<?php echo!empty($saved_data['patient']['representative_date']) ? $saved_data['patient']['representative_date'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-flex justify-content-start col-md-6 col-sm-12 col-12 align-items-start form-group">
<div class="d-flex justify-content-start align-items-start col-md-12 col-sm-12 col-12 date_field flex-column">
<label>Legal Representative Phone (If different from above)</label>
<input class="form-control" name="patient[representative_phone]" type="tel" id="patient_representative_phone" value="<?php echo!empty($saved_data['patient']['representative_phone']) ? $saved_data['patient']['representative_phone'] : "" ?>">
</div>
</div>
<div class="d-flex justify-content-end col-md-6 col-sm-12 col-12 date_field form-group align-items-start flex-column">
<label>Relationship to Patient </label>
<input class="form-control" name="patient[relationship_to_patient]" type="text" id="patient_relationship_to_patient" value="<?php echo!empty($saved_data['patient']['relationship_to_patient']) ? $saved_data['patient']['relationship_to_patient'] : "" ?>">
</div>
</div>
<div class="one_line mp-10 col-md-12 col-sm-12 col-12 d-flex form-group justify-content-start flex-column align-items-center">
<div class="d-flex justify-content-start col-12 txt-11 text-pink">
<strong>TEZSPIRE Together Fast Start Terms & Conditions (Commercially Insured Patients Only)</strong>
</div>
<div class="d-flex justify-content-start col-12 txt13 mb-2 align-items-center">
If you have commercial insurance and your health plan does not cover TEZSPIRE or requires a prior authorization, you may be eligible to receive TEZSPIRE free for up to twelve (12) doses within twenty-four (24) months from the date the first dose is filled. See full Terms and Conditions listed below.
</div>
<div class="d-flex justify-content-start col-12 txt-11 align-items-center">
<input type="checkbox" name="patient[agree_tc]" id="checkbox25" required value="1" <?php echo!empty($saved_data['patient']['agree_tc']) && $saved_data['patient']['agree_tc'] == 1 ? "checked" : "" ?>"> By checking this box, I agree that I read, understand, and accept the <strong>Terms and Conditions</strong> of the Fast Start Program.
</div>
</div>
</div>
<div class="section_two col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-4 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">2</div>
<div class="d-flex ml-2 col-md-11 col-sm-11 col-12 header-title txt-8 text-pink">INSURANCE INFORMATION</div>
</div>
<div class="d-flex justify-content-end align-items-center col-md-8 col-sm-12 col-12 form-group">
<div class="d-flex justify-content-start align-items-center px-1">
<input class="insurance_type" type="checkbox" name="insurance_provider[insurance_type]" id="insurance_provider_insurance_type" value="commercial_insurance" <?php echo!empty($saved_data['insurance_provider']['insurance_type']) && $saved_data['insurance_provider']['insurance_type'] == "commercial_insurance" ? "checked" : "" ?>">
<label>Commercial/Private Insurance</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="insurance_type" type="checkbox" name="insurance_provider[insurance_type]" id="insurance_provider_insurance_type" value="tricare" <?php echo!empty($saved_data['insurance_provider']['insurance_type']) && $saved_data['insurance_provider']['insurance_type'] == "tricare" ? "checked" : "" ?>">
<label>Medicare/Medicaid/TRICARE</label>
</div>
<div class="d-flex justify-content-start align-items-center px-1">
<input class="insurance_type" type="checkbox" name="insurance_provider[insurance_type]" id="insurance_provider_insurance_type" value="no_insurance" <?php echo!empty($saved_data['insurance_provider']['insurance_type']) && $saved_data['insurance_provider']['insurance_type'] == "no_insurance" ? "checked" : "" ?>">
<label>No Insurance</label>
</div>
</div>
</div>
<div class="patient_insurance_form d-flex flex-column">
<div class="one_line mp-10 col-md-12 col-sm-12 col-12 d-flex form-group justify-content-start flex-column align-items-center">
<div class="d-flex justify-content-start col-12 txt-11">
If you are acquiring the product via buy and bill, medical insurance is required. If you are acquiring via Specialty Pharmacy, provide both medical and pharmacy insurance information to see if medical insurance could result in a lower out-of-pocket cost for your patient.
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center px-3">
<h4>Primary Medical Insurance*</h4>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Provider:* </label>
<input class="form-control" name="insurance_provider[name]" type="text" id="insurance_provider_name" value="<?php echo!empty($saved_data['insurance_provider']['name']) ? $saved_data['insurance_provider']['name'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Phone #:* </label>
<input class="form-control" name="insurance_provider[phone]" type="text" id="insurance_provider_phone" value="<?php echo!empty($saved_data['insurance_provider']['phone']) ? $saved_data['insurance_provider']['phone'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Cardholder Name (if not the patient): </label>
<input class="form-control" name="insurance_provider[cardholder_name]" type="text" id="insurance_provider_cardholder_name" value="<?php echo!empty($saved_data['insurance_provider']['cardholder_name']) ? $saved_data['insurance_provider']['cardholder_name'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group date_field">
<label class="text-label">Cardholder Date of Birth:* </label>
<input class="form-control" name="insurance_provider[cardholder_dob]" type="date" id="insurance_provider_cardholder_dob" value="<?php echo!empty($saved_data['insurance_provider']['cardholder_dob']) ? $saved_data['insurance_provider']['cardholder_dob'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Policy #:* </label>
<input class="form-control" name="insurance_provider[policy]" type="text" id="insurance_provider_policy" value="<?php echo!empty($saved_data['insurance_provider']['policy']) ? $saved_data['insurance_provider']['policy'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Group #:* </label>
<input class="form-control" name="insurance_provider[group]" type="text" id="insurance_provider_group" value="<?php echo!empty($saved_data['insurance_provider']['group']) ? $saved_data['insurance_provider']['group'] : "" ?>">
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center px-3">
<h4>Pharmacy Insurance</h4>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Provider: </label>
<input class="form-control" name="pharmacy[name]" type="text" id="pharmacy_name" value="<?php echo!empty($saved_data['pharmacy']['name']) ? $saved_data['pharmacy']['name'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Phone #: </label>
<input class="form-control" name="pharmacy[phone]" type="text" id="pharmacy_phone" value="<?php echo!empty($saved_data['pharmacy']['phone']) ? $saved_data['pharmacy']['phone'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Cardholder Name (if not the patient): </label>
<input class="form-control" name="pharmacy[cardholder_name]" type="text" id="pharmacy_cardholder_name" value="<?php echo!empty($saved_data['pharmacy']['cardholder_name']) ? $saved_data['pharmacy']['cardholder_name'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group date_field">
<label class="text-label">Cardholder Date of Birth: </label>
<input class="form-control" name="pharmacy[cardholder_dob]" type="date" id="pharmacy_cardholder_dob" value="<?php echo!empty($saved_data['pharmacy']['cardholder_dob']) ? $saved_data['pharmacy']['cardholder_dob'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Policy #: </label>
<input class="form-control" name="pharmacy[policy]" type="text" id="pharmacy_policy" value="<?php echo!empty($saved_data['pharmacy']['policy']) ? $saved_data['pharmacy']['policy'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Group #: </label>
<input class="form-control" name="pharmacy[group]" type="text" id="pharmacy_group" value="<?php echo!empty($saved_data['pharmacy']['group']) ? $saved_data['pharmacy']['group'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">RxBIN: </label>
<input class="form-control" name="pharmacy[rxbin]" type="text" id="pharmacy_rxbin" value="<?php echo!empty($saved_data['pharmacy']['rxbin']) ? $saved_data['pharmacy']['rxbin'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">RxPCN: </label>
<input class="form-control" name="pharmacy[rxpcn]" type="text" id="pharmacy_rxpcn" value="<?php echo!empty($saved_data['pharmacy']['rxpcn']) ? $saved_data['pharmacy']['rxpcn'] : "" ?>">
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center px-3">
<h4>Secondary Medical Insurance</h4>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Provider: </label>
<input class="form-control" name="medical[name]" type="text" id="medical_name" value="<?php echo!empty($saved_data['medical']['name']) ? $saved_data['medical']['name'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Insurance Phone #: </label>
<input class="form-control" name="medical[phone]" type="text" id="medical_phone" value="<?php echo!empty($saved_data['medical']['phone']) ? $saved_data['medical']['phone'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Cardholder Name (if not the patient): </label>
<input class="form-control" name="medical[cardholder_name]" type="text" id="medical_cardholder_name" value="<?php echo!empty($saved_data['medical']['cardholder_name']) ? $saved_data['medical']['cardholder_name'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group date_field">
<label class="text-label">Cardholder Date of Birth: </label>
<input class="form-control" name="medical[cardholder_dob]" type="date" id="medical_cardholder_dob" value="<?php echo!empty($saved_data['medical']['cardholder_dob']) ? $saved_data['medical']['cardholder_dob'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Policy #: </label>
<input class="form-control" name="medical[policy]" type="text" id="medical_policy" value="<?php echo!empty($saved_data['medical']['policy']) ? $saved_data['medical']['policy'] : "" ?>">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Group #: </label>
<input class="form-control" name="medical[group]" type="text" id="medical_group" value="<?php echo!empty($saved_data['medical']['group']) ? $saved_data['medical']['group'] : "" ?>">
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 text-center justify-content-start align-items-center p-4 txt10 text-purple">
<strong>Patient or legal representative:</strong> visit <strong>TEZSPIRETogether.com</strong> or call <strong>1-888-TZSPIRE (1-888-897-7473)</strong><br>
to enroll in the TEZSPIRE Together Co-pay Program (for eligible commercially insured patients only) or to see if you may be eligible for other financial support.
</div>
<!-- <div class="one_line col-md-8 col-sm-12 col-12 text-center justify-content-start align-items-center p-4 txt10 text-purple note_section">
<strong>Note: </strong>Patient and Insurance Information should be completed by the patient<br> or their legal guardian/caregiver.
</div>-->
<div class="one_line col-md-12 col-sm-12 col-12 text-center text-bold justify-content-start align-items-center px-3 txt13 text-purple">
Please see Indication and Important Safety Information listed below.
</div>
</div>
</div>
<div class="section_three col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-6 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">3</div>
<div class="d-flex ml-2 col-md-11 col-sm-11 col-12 header-title txt-8 text-pink">PROGRAM SERVICES</div>
</div>
<div class="d-flex col-md-6 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex no_insurance justify-content-end col-md-12 col-sm-12 col-12 align-items-center text-white px-2">
<input type="file" id="upload" name="program_service[insurance_attachment]" hidden/>
<label for="upload">Attach File</label>
</div>
</div>
</div>
<div class="program_service_form p-2">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex form-group justify-content-start flex-column align-items-center">
<div class="one_line how_obtain col-md-12 col-12 d-flex justify-content-between align-items-center icd_code_section height-58">
<!--<div class="d-flex primary_diag_code justify-content-start align-items-center col-md-4 col-sm-12 col-12">-->
<div class="d-flex diagnosis_code_category justify-content-start align-items-center">
<label style="width: 230px;">How will you obtain TEZSPIRE?*</label>
<div class="d-flex justify-content-center align-items-center col-md-4 col-sm-12 col-12">
<input class="how_obtain_check" type="checkbox" name="program_service[how_will_you_obtain_tezspire]" id="patient_insurance_type" value="buyandbill" <?php echo!empty($saved_data['program_service']['how_will_you_obtain_tezspire']) && $saved_data['program_service']['how_will_you_obtain_tezspire'] == "buyandbill" ? "checked" : "" ?>">
<label>Buy and Bill</label>
</div>
</div>
<!--</div>-->
<div class="d-flex spc_pharmacy_field justify-content-start align-items-center">
<div class="d-flex spc_pharmacy_field justify-content-start align-items-center">
<input class="spc_pharmacy how_obtain_check" type="checkbox" name="program_service[how_will_you_obtain_tezspire]" id="patient_insurance_type" value="select_pharmacy" <?php echo!empty($saved_data['program_service']['how_will_you_obtain_tezspire']) && $saved_data['program_service']['how_will_you_obtain_tezspire'] == "select_pharmacy" ? "checked" : "" ?>">
<label class="spc_pharmacy_label">Specialty Pharmacy (complete section 6): </label>
</div>
</div>
<div class="d-flex primary_diag_code justify-content-start">
<div class="d-flex justify-content-start align-items-center col-md-12 col-sm-12 col-12" style="width: 230px;">
<input class="how_obtain_check" type="checkbox" name="program_service[how_will_you_obtain_tezspire]" id="patient_insurance_type" value="not_sure" <?php echo!empty($saved_data['program_service']['how_will_you_obtain_tezspire']) && $saved_data['program_service']['how_will_you_obtain_tezspire'] == "not_sure" ? "checked" : "" ?>">
<label>I’m Not Sure</label>
</div>
</div>
</div>
<div id="spc_pharmacy_text" class="one_line col-md-12 col-12">
<div id="spc_pharmacy_text_div" class="spc_pharmacy_field justify-content-start align-items-center col-md-6 col-sm-12 col-12">
<input class="form-control txt2 spc_pharmacy_text_field" placeholder="Preferred Specialty Pharmacy" name="program_service[spc_pharmacy]" id="program_service_spc_pharmacy" type="text" value="<?php echo!empty($saved_data['program_service']['spc_pharmacy']) ? $saved_data['program_service']['spc_pharmacy'] : "" ?>">
</div>
<div class="d-flex primary_diag_code justify-content-end align-items-center col-md-6 col-sm-12 col-12">
<div class="d-flex diagnosis_code_category justify-content-start align-items-center">
<label>Site Type: </label>
<div class="d-flex justify-content-center align-items-center">
<input class="how_obtain_check_hpo" type="checkbox" name="program_service[hpo]" value="hpo" <?php echo!empty($saved_data['program_service']['hpo']) && $saved_data['program_service']['hpo'] == "hpo" ? "checked" : "" ?>">
<label>Healthcare Provider Office</label>
<input class="how_obtain_check_hpo" type="checkbox" name="program_service[ho]" value="ho" <?php echo!empty($saved_data['program_service']['ho']) && $saved_data['program_service']['ho'] == "ho" ? "checked" : "" ?>">
<label>Hospital Outpatient</label>
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-start col-12 txt3 text-pink">
<strong>TEZSPIRE Together Service Request (check all that apply):</strong>
</div>
<div class="d-flex d-flex-mobile justify-content-start col-12 txt-11 align-items--start date_field">
<input type="checkbox" name="program_service[benefit_verification]" id="program_service_benefit_verification" value="1" <?php echo!empty($saved_data['program_service']['benefit_verification']) && $saved_data['program_service']['benefit_verification'] == "1" ? "checked" : "" ?>">
<label><strong>Benefits Verification: </strong>Verify your patient’s insurance coverage for TEZSPIRE and obtain a Summary of Benefits.</label>
</div>
<div class="d-flex pl-3 d-flex-mobile justify-content-start col-12 txt-11 align-items-start">
<input type="checkbox" name="program_service[transfer_to_specialty_pharmacy]" id="program_service_transfer_to_specialty_pharmacy" value="1" <?php echo!empty($saved_data['program_service']['transfer_to_specialty_pharmacy']) && $saved_data['program_service']['transfer_to_specialty_pharmacy'] == "1" ? "checked" : "" ?>">
<label><strong>Transfer to Specialty Pharmacy: </strong>TEZSPIRE Together will transfer the Rx to the preferred or mandated Specialty Pharmacy (complete section 6).</label>
</div>
<div class="d-flex d-flex-mobile justify-content-start col-12 txt-11 align-items-start">
<input type="checkbox" name="program_service[fast_start_program]" id="program_service_fast_start_program" value="1" <?php echo!empty($saved_data['program_service']['fast_start_program']) && $saved_data['program_service']['fast_start_program'] == "1" ? "checked" : "" ?>">
<label><strong>Fast Start Program: </strong>The Fast Start Program provides up to 12 free doses to eligible commercially insured patients whose plans do not cover TEZSPIRE or require a prior authorization (PA). For immediate enrollment in Fast Start, please complete section 6 and check the box for Fast Start and confirm the patient has completed section 1. TEZSPIRE Together will run a Benefits Verification to confirm eligibility even if the service isn't requested above.
</div>
<div class="d-flex pl-3 d-flex-mobile justify-content-start col-12 txt-11 align-items-start">
<input type="checkbox" name="program_service[acknowledge]" id="program_service_acknowledge" value="1" <?php echo!empty($saved_data['program_service']['acknowledge']) && $saved_data['program_service']['acknowledge'] == "1" ? "checked" : "" ?>">
<label>By checking this box, I acknowledge that the PA must be submitted within 60 days of the first Fast Start shipment. Additionally, if the PA is denied, an appeal must be submitted within 60 days of denial. Noncompliance with these terms will result in the patient no longer being eligible for the Fast Start Program.</label>
</div>
<div class="d-flex d-flex-mobile justify-content-start col-12 txt-11 align-items-start">
<input type="checkbox" name="program_service[pa_support]" id="program_service_pa_support" value="1" <?php echo!empty($saved_data['program_service']['pa_support']) && $saved_data['program_service']['pa_support'] == "1" ? "checked" : "" ?>">
<label><strong>PA and Appeals Support: </strong> Identify the PA and appeal requirements based on plan criteria, help initiate and submit a PA, and track the status of a submission.</label>
</div>
</div>
</div>
</div>
<div class="section_four col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-6 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">4</div>
<div class="d-flex ml-2 col-md-11 col-sm-11 col-12 header-title txt-8 text-pink">CLINICAL INFORMATION </div>
</div>
</div>
<div class="clinical_information_form p-2">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center flex-column">
<div class="col-md-12 col-12 d-flex height-58 justify-content-between align-items-center icd_code_section px-2">
<div class="d-flex primary_diag_code justify-content-start align-items-center">
<div class="d-flex icd_code_category justify-content-start align-items-center col-12">
<label style="width: 160px;"><b>ICD-10-CM Code:*</b></label>
<div class="d-flex d-flex-mobile justify-content-start align-items-start txt13">
<input class="icd_code" type="checkbox" name="clinical[icd_code]" id="clinical_icd_code_j4550" value="j4550" <?php echo!empty($saved_data['clinical']['icd_code']) && $saved_data['clinical']['icd_code'] == "j4550" ? "checked" : "" ?>">
<label>J45.50 Severe persistent asthma, uncomplicated</label>
</div>
</div>
</div>
<div class="d-flex primary_diag_code justify-content-start">
<div class="d-flex d-flex-mobile justify-content-start align-items-start txt13">
<input class="icd_code" type="checkbox" name="clinical[icd_code]" id="clinical_j4551" value="j4551" <?php echo!empty($saved_data['clinical']['icd_code']) && $saved_data['clinical']['icd_code'] == "j4551" ? "checked" : "" ?>">
<label>J45.51 Severe persistent asthma with (acute) exacerbation</label>
</div>
</div>
<div class="d-flex icd_code_other_field justify-content-start align-items-start">
<input class="icd_code icd_code_other" type="checkbox" name="clinical[icd_code]" id="clinical_icd_code_other" value="other" <?php echo!empty($saved_data['clinical']['icd_code']) && $saved_data['clinical']['icd_code'] == "other" ? "checked" : "" ?>">
<label class="icd_code_other_label txt13">Other/Misc: </label>
<input id="icd_code_other_text" class="form-control" type="text" name="clinical[icd_code_other_text]" id="clinical_icd_code_other_text" value="<?php echo!empty($saved_data['clinical']['icd_code_other_text']) ? $saved_data['clinical']['icd_code_other_text'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex justify-content-start col-md-6 col-sm-12 col-12 form-group">
<label class="text-label">Known Drug Allergies*: </label>
<input class="form-control" name="clinical[known_drug_allergies]" type="text" id="clinical_known_drug_allergies" required value="<?php echo!empty($saved_data['clinical']['known_drug_allergies']) ? $saved_data['clinical']['known_drug_allergies'] : "" ?>">
</div>
<div class="d-flex d-flex-mobile justify-content-start align-items-start col-md-6 col-sm-12 col-12 form-group">
<input type="checkbox" name="checkbox24" id="checkbox25" class="mt-1" name="clinical[history]" id="clinical_history" value="1" <?php echo!empty($saved_data['clinical']['history']) && $saved_data['clinical']['history'] == "1" ? "checked" : "" ?>">
<label>History of positive skin or specific IgE (test to perennial aeroallergen)</label>
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group input-group">
<label class="text-label">Absolute Eosinophil Count: </label>
<input class="form-control" name="clinical[absolute_eosinophil_count]" type="text" id="clinical_absolute_eosinophil_count" value="<?php echo!empty($saved_data['clinical']['absolute_eosinophil_count']) ? $saved_data['clinical']['absolute_eosinophil_count'] : "" ?>">
<div class="input-group-append">
<span class="input-group-text" id="basic-addon2">cells/mcL</span>
</div>
</div>
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group date_field">
<label class="text-label">Test Date: </label>
<input class="form-control" type="date" name="clinical[test_date]" id="clinical_test_date" value="<?php echo!empty($saved_data['clinical']['test_date']) ? $saved_data['clinical']['test_date'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group input-group">
<label class="text-label">Pre-treatment serum IgE level: </label>
<input class="form-control" type="text" name="clinical[pre_treatment_serum]" id="clinical_pre_treatment_serum" value="<?php echo!empty($saved_data['clinical']['pre_treatment_serum']) ? $saved_data['clinical']['pre_treatment_serum'] : "" ?>">
<div class="input-group-append">
<span class="input-group-text" id="basic-addon2">IU/mL</span>
</div>
</div>
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group date_field">
<label class="text-label">Test Date: </label>
<input class="form-control" type="date" name="clinical[test_date2]" id="clinical_test_date2" value="<?php echo!empty($saved_data['clinical']['test_date2']) ? $saved_data['clinical']['test_date2'] : "" ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center py-0">
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group">
<label class="text-label">Number of severe asthma exacerbations in the past 12 months: </label>
<input class="form-control" type="text" name="clinical[no_of_severe_asthama]" id="clinical_no_of_severe_asthama" value="<?php echo!empty($saved_data['clinical']['no_of_severe_asthama']) ? $saved_data['clinical']['no_of_severe_asthama'] : "" ?>">
</div>
<div class="d-flex d-flex-mobile justify-content-start col-md-6 col-sm-12 col-12 form-group">
<label class="text-label">Number of ED visits or hospitalizations in the past 12 months: </label>
<input class="form-control" type="text" name="clinical[no_of_ed_visits]" id="clinical_no_of_ed_visits" value="<?php echo!empty($saved_data['clinical']['no_of_ed_visits']) ? $saved_data['clinical']['no_of_ed_visits'] : "" ?>">
</div>
</div>
</div>
</div>
</div>
<div class="section_five col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-6 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">5</div>
<div class="d-flex ml-2 col-md-11 col-sm-11 col-12 header-title txt-8 text-pink">PRESCRIBER INFORMATION</div>
</div>
</div>
<div class="prescriber_form d-flex justify-content-start align-items-center col-md-12 col-sm-12 col-12 flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center">
<div class="d-flex d-flex-mobile justify-content-start col-md-4 col-sm-12 col-12 form-group pb-0 npi_provider">
<label class="text-label">Search Provider by NPI </label>
<input class="form-control" type="text" name="prescriber[npi]" id="prescriber_npi" class="requiredval" value="<?php echo!empty($saved_data['prescriber']['npi']) ? $saved_data['prescriber']['npi'] : ''; ?>">
<button type="submit" name="submit2" id="submit2" value="Search" class="btn bg-purple px-4 text-white">Search</button>
</div>
</div>
<div class="prescriber_form_fields d-flex justify-content-start align-items-start col-md-12 col-sm-12 col-12 flex-column">
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Prescriber Name:* </label>
<input class="form-control" name="prescriber[name]" type="text" value="<?php echo!empty($saved_data['prescriber']['name']) ? $saved_data['prescriber']['name'] : ''; ?>" id="prescriber_fname" class="requiredval">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Prescriber NPI #:* </label>
<input class="form-control" name="prescriber[npi]" type="text" value="<?php echo!empty($saved_data['prescriber']['npi']) ? $saved_data['prescriber']['npi'] : ''; ?>" id="prescriber_npi" class="requiredval">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Practice/Clinic Name: </label>
<input class="form-control" name="prescriber[practice_name]" type="text" value="<?php echo!empty($saved_data['prescriber']['practice_name']) ? $saved_data['prescriber']['practice_name'] : ''; ?>" id="prescriber_practice_name" class="requiredval">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Office Contact Name: </label>
<input class="form-control" name="prescriber[office_contact]" type="text" value="<?php echo!empty($saved_data['prescriber']['office_contact']) ? $saved_data['prescriber']['office_contact'] : ''; ?>" id="prescriber_office_contact" class="mobval">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Address Line1:* </label>
<input class="form-control" name="prescriber[address]" type="text" value="<?php echo!empty($saved_data['prescriber']['address']) ? $saved_data['prescriber']['address'] : ''; ?>" id="prescriber_address" class="requiredval">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Address Line2:* </label>
<input class="form-control" name="prescriber[address2]" type="text" value="<?php echo!empty($saved_data['prescriber']['address2']) ? $saved_data['prescriber']['address2'] : ''; ?>" id="prescriber_address2" class="requiredval">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">City:* </label>
<input class="form-control" name="prescriber[city]" type="text" id="prescriber_city" value="<?php echo!empty($saved_data['prescriber']['city']) ? $saved_data['prescriber']['city'] : ''; ?>" class="requiredval">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">State:* </label>
<select name="prescriber[state]" id="prescriber_state" class="requiredval selectbox form-control" >
<option value=""></option>
<option value="AL" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'AL')) ? 'selected' : ''; ?>>Alabama</option>
<option value="AK" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'AK')) ? 'selected' : ''; ?>>Alaska</option>
<option value="AZ" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'AZ')) ? 'selected' : ''; ?>>Arizona</option>
<option value="AR" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'AR')) ? 'selected' : ''; ?>>Arkansas</option>
<option value="CA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'CA')) ? 'selected' : ''; ?>>California</option>
<option value="CO" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'CO')) ? 'selected' : ''; ?>>Colorado</option>
<option value="CT" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'CT')) ? 'selected' : ''; ?>>Connecticut</option>
<option value="DE" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'DE')) ? 'selected' : ''; ?>>Delaware</option>
<option value="DC" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'DC')) ? 'selected' : ''; ?>>District Of Columbia</option>
<option value="FL" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'FL')) ? 'selected' : ''; ?>>Florida</option>
<option value="GA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'GA')) ? 'selected' : ''; ?>>Georgia</option>
<option value="HI" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'HI')) ? 'selected' : ''; ?>>Hawaii</option>
<option value="ID" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'ID')) ? 'selected' : ''; ?>>Idaho</option>
<option value="IL" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'IL')) ? 'selected' : ''; ?>>Illinois</option>
<option value="IN" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'IN')) ? 'selected' : ''; ?>>Indiana</option>
<option value="IA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'IA')) ? 'selected' : ''; ?>>Iowa</option>
<option value="KS" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'KS')) ? 'selected' : ''; ?>>Kansas</option>
<option value="KY" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'KY')) ? 'selected' : ''; ?>>Kentucky</option>
<option value="LA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'LA')) ? 'selected' : ''; ?>>Louisiana</option>
<option value="ME" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'ME')) ? 'selected' : ''; ?>>Maine</option>
<option value="MD" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MD')) ? 'selected' : ''; ?>>Maryland</option>
<option value="MA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MA')) ? 'selected' : ''; ?>>Massachusetts</option>
<option value="MI" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MI')) ? 'selected' : ''; ?>>Michigan</option>
<option value="MN" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MN')) ? 'selected' : ''; ?>>Minnesota</option>
<option value="MS" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MS')) ? 'selected' : ''; ?>>Mississippi</option>
<option value="MO" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MO')) ? 'selected' : ''; ?>>Missouri</option>
<option value="MT" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'MT')) ? 'selected' : ''; ?>>Montana</option>
<option value="NE" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NE')) ? 'selected' : ''; ?>>Nebraska</option>
<option value="NV" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NV')) ? 'selected' : ''; ?>>Nevada</option>
<option value="NH" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NH')) ? 'selected' : ''; ?>>New Hampshire</option>
<option value="NJ" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NJ')) ? 'selected' : ''; ?>>New Jersey</option>
<option value="NM" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NM')) ? 'selected' : ''; ?>>New Mexico</option>
<option value="NY" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NY')) ? 'selected' : ''; ?>>New York</option>
<option value="NC" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'NC')) ? 'selected' : ''; ?>>North Carolina</option>
<option value="ND" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'ND')) ? 'selected' : ''; ?>>North Dakota</option>
<option value="OH" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'OH')) ? 'selected' : ''; ?>>Ohio</option>
<option value="OK" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'OK')) ? 'selected' : ''; ?>>Oklahoma</option>
<option value="OR" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'OR')) ? 'selected' : ''; ?>>Oregon</option>
<option value="PA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'PA')) ? 'selected' : ''; ?>>Pennsylvania</option>
<option value="RI" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'RI')) ? 'selected' : ''; ?>>Rhode Island</option>
<option value="SC" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'SC')) ? 'selected' : ''; ?>>South Carolina</option>
<option value="SD" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'SD')) ? 'selected' : ''; ?>>South Dakota</option>
<option value="TN" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'TN')) ? 'selected' : ''; ?>>Tennessee</option>
<option value="TX" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'TX')) ? 'selected' : ''; ?>>Texas</option>
<option value="UT" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'UT')) ? 'selected' : ''; ?>>Utah</option>
<option value="VT" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'VT')) ? 'selected' : ''; ?>>Vermont</option>
<option value="VA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'VA')) ? 'selected' : ''; ?>>Virginia</option>
<option value="WA" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'WA')) ? 'selected' : ''; ?>>Washington</option>
<option value="WV" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'WV')) ? 'selected' : ''; ?>>West Virginia</option>
<option value="WI" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'WI')) ? 'selected' : ''; ?>>Wisconsin</option>
<option value="WY" <?php echo (!empty($saved_data['prescriber']['state']) && ($saved_data['prescriber']['state'] == 'WY')) ? 'selected' : ''; ?>>Wyoming</option>
</select>
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">ZIP Code:* </label>
<input class="form-control zip_field zipval" name="prescriber[zip]" type="text" id="prescriber_zip" value="<?php echo!empty($saved_data['prescriber']['zip']) ? $saved_data['prescriber']['zip'] : ''; ?>">
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center">
<!-- <div class="d-flex justify-content-start col-12 form-group">
<label class="text-label">Phone:* </label>
<input class="form-control" name="textfield45" type="tel" id="textfield51">
</div>-->
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Phone:* </label>
<input class="form-control mobval" name="prescriber[phone]" type="text" value="<?php echo!empty($saved_data['prescriber']['phone']) ? $saved_data['prescriber']['phone'] : ''; ?>" id="prescriber_phone">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Fax:* </label>
<input class="form-control mobval" name="prescriber[fax]" type="text" value="<?php echo!empty($saved_data['prescriber']['fax']) ? $saved_data['prescriber']['fax'] : ''; ?>" id="prescriber_fax">
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-12 col-12 form-group">
<label class="text-label">Office Contact Email: </label>
<input class="form-control emailval" name="prescriber[email]" type="text" value="<?php echo!empty($saved_data['prescriber']['email']) ? $saved_data['prescriber']['email'] : ''; ?>" id="prescriber_email">
</div>
</div>
</div>
</div>
</div>
<div class="section_six col-md-12 col-12 align-items-start justify-content-evenly txt2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-12 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex header_no bg-purple txt-7">6</div>
<div class="d-flex ml-2 col-md-11 col-sm-11 col-12 header-title txt-8 text-pink align-items-end">PRESCRIPTION INFORMATION <span class="txt5 text-pink pb-1 px-1 prec_info_sub_text">(complete this section if you are using a Specialty Pharmacy and/or the Fast Start Program)</span></div>
</div>
</div>
<div class="prescriber_certification_form p-2">
<div class="prescriber_certification">
<div class="one_line col-md-12 col-12 d-flex justify-content-start align-items-start flex-column">
<div class="d-flex justify-content-start col-md-12 col-sm-12 col-12 flex-wrap">
<div class="d-flex d-flex-mobile justify-content-start col-md-12 col-sm-12 col-12 flex-nowrap align-items-start">
<input class="rx_80_mg presc_certi" type="checkbox" name="prescription_info[prescription]" id="prescription_info_prescription" value="1" <?php echo!empty($saved_data['prescription_info']['prescription']) && $saved_data['prescription_info']['prescription'] == "1" ? "checked" : "" ?>">
<div>
<strong><font class="text-purple text-bold ng-mt-3">Prescription: TEZSPIRE (tezepelumab-ekko)</font></strong> 210 mg/1.91 mL (110 mg/mL) single-dose prefilled syringe injection
</div>
</div>
<div class="px-3 d-flex sig_section align-items-center col-md-12 col-sm-12 col-12 flex-column">
<div class="one_line d-flex align-items-center col-md-12 col-sm-12 col-12">
SIG: 210 mg administered SC once every 4 weeks
</div>
<div class="one_line d-block align-items-center col-md-12 col-sm-12 col-12">
<strong>Office Administered</strong> (NDC: 55513-112-01)
</div>
<div class="one_line d-flex refill_section align-items-center col-md-12 col-sm-12 col-12">
<div id="quantity_dispensed_text" class="d-flex align-items-center col-md-5 col-sm-12 col-12"><strong class="word_break">Quantity Dispensed:* </strong>
<input name="prescription_info[quantity_dispensed]" type="text" class="uinput form-control" id="prescription_info_quantity_dispensed" value="<?php echo!empty($saved_data['prescription_info']['quantity_dispensed']) ? $saved_data['prescription_info']['quantity_dispensed'] : ''; ?>">
</div>
<div id="rx_80_mg_text" class="d-flex align-items-center"> <strong>Refills:* </strong>
<input name="prescription_info[refills]" type="text" class="uinput form-control" id="prescription_info_refills" value="<?php echo!empty($saved_data['prescription_info']['refills']) ? $saved_data['prescription_info']['refills'] : ''; ?>">
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-start col-md-12 col-sm-12 col-12 flex-wrap mt-3">
<div class="d-flex d-flex-mobile justify-content-start col-md-12 col-sm-12 col-12 flex-nowrap align-items-start">
<input class="rx_80_mg presc_certi" type="checkbox" name="prescription_info[fast_start]" id="checkbox4" value="1" <?php echo!empty($saved_data['prescription_info']['fast_start']) && $saved_data['prescription_info']['fast_start'] == "1" ? "checked" : "" ?>>
<div>
<strong><font class="text-purple text-dark ng-mt-3">Fast Start: </font></strong> Optional program that provides up to 12 free doses of TEZSPIRE to eligible commercially insured patients whose plans do not cover TEZSPIRE or require a PA
</div>
</div>
<div class="px-3 d-flex sig_section align-items-center col-md-12 col-sm-12 col-12 flex-column">
<div class="one_line d-flex align-items-center col-md-12 col-sm-12 col-12">
SIG: 210 mg administered SC once every 4 weeks
</div>
<div class="one_line d-block align-items-center col-md-12 col-sm-12 col-12">
<strong>Office Administered</strong> (NDC: 55513-112-01)
</div>
<div class="one_line d-flex refill_section align-items-center col-md-12 col-sm-12 col-12">
<div id="quantity_dispensed_text" class="d-flex align-items-center col-md-5 col-sm-12 col-12"><strong class="word_break">Quantity Dispensed:* </strong>
<input name="prescription_info[fast_start_quantity_dispensed]" type="text" class="uinput form-control" id="prescription_info_quantity_dispensed" value="<?php echo!empty($saved_data['prescription_info']['quantity_dispensed']) ? $saved_data['prescription_info']['quantity_dispensed'] : ''; ?>">
</div>
<div id="rx_80_mg_text" class="d-flex align-items-center"> <strong>Refills:* </strong>
<input name="prescription_info[fast_start_refills]" type="text" class="uinput form-control" id="prescription_info_refills" value="<?php echo!empty($saved_data['prescription_info']['refills']) ? $saved_data['prescription_info']['refills'] : ''; ?>">
</div>
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-12 d-block justify-content-start align-items-center">
<strong>Prescriber Attestation:</strong> If TEZSPIRE is shipped to the prescriber’s office, the prescriber accepts TEZSPIRE on behalf of the patient for administration in the office. The prescriber is to comply with his/her state-specific prescription requirements such as e-prescribing, state-specific prescription form, fax language, etc. Noncompliance with state-specific requirements could result in outreach to the prescriber.
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-start align-items-center ">
By signing below, I certify as a licensed healthcare professional that the patient named on this form has, or has had, a diagnosis for an FDA-approved indication for
TEZSPIRE. I also certify that this is my legal signature.
</div>
<div class="col-md-12 col-12 d-flex justify-content-between align-items-center">
<div class="one_line dispense_written col-md-6 col-12 d-flex justify-content-start align-items-center flex-column pr-2">
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-block justify-content-start align-items-center px-2">
Dispense as Written/Brand Medically Necessary/Do Not Substitute/No Substitution/May Not Substitute
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-start">
<div class="d-flex justify-content-start col-md-8 col-sm-6 col-12 align-items-center px-2">
<div class="d-flex justify-content-between col-md-12 col-sm-12 col-12 align-items-center flex-column">
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center">
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center flex-column">
<label class="text-pink col-md-12 col-sm-12 col-12 txt13"><b>Prescriber Signature (dispense as written)</b></label>
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center">
<img class="pat-sign-img" src="images/arrow.png" alt="">
<div class="signature_div">
<div class="mb-1"><a class="button" id="hcprovider_0_click_to_sign" onclick="" href="#popup2" rel="modal:open">Click here to sign</a></div>
<div class="hcprovider_0_signed signed">
<div class="sigWrapper">
<a href="#popup2" rel="modal:open"><div class="typed" id="hcprovider_0_typed"></div></a>
<a href="#popup2" rel="modal:open"><canvas class="pad" id="hcprovider_0_draw" width="198" height="55"></canvas></a>
</div>
</div>
<input type="hidden" name="prescription_info[signature]" id="hcprovider_0_signature_name" value="" />
<input type="hidden" name="prescription_info[signature]" id="hcprovider_0_signImageFile" value="" />
<div id="popup2" class="modal">
<div class="content">
<canvas id="signature-pad" class="signature-pad" width=198 height=55></canvas>
<!-- <div id="sig" style="width:50%; min-heght:50px;height: 235px;">
<div class="hcprovider_0_sigPad">
<label for="name" id="print_name">Print your name</label>
<input type="text" name="hcprovider[0][consent_name]" id="hcprovider_0_consent_name" class="name data" style="padding-left: 5px;">
<p class="typeItDesc">Review your signature</p>
<p class="drawItDesc">Draw your signature</p>
--> <ul class="sigNav">
<li class="typeIt"><a href="#type-it" class="current">Type It</a></li>
<li class="drawIt"><a id="save" href="#draw-it" >Draw It</a></li>
<li class="clearButton"><a id="clear" href="#clear">Clear</a></li>
</ul><!--
<div class="sig sigWrapper">
<div class="typed"></div>
<canvas class="pad" id="signature-pad-canvas" width="350" height="100"></canvas>
<input type="hidden" name="output" class="output">
</div>
<br />
<input type="button" id="hcprovider_0_save" value="Save" />
</div>
</div>-->
<textarea id="hcprovider_0_signature64" name="prescription_info[signature64]" style="display: none"></textarea>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-6 col-12 date_field align-items-center flex-column height-64">
<label class="text-pink col-md-12 col-sm-12 col-12"><b>Date:</b> </label>
<input class="form-control date-format local" name="prescription_info[consent_date]" type="date" id="hcprovider_consent_date" value="<?php echo!empty($saved_data['hcprovider']['consent_date']) ? $saved_data['hcprovider']['consent_date'] : ''; ?>">
</div>
</div>
</div>
<div class="one_line align-items-center">
<div class="br1"></div>
</div>
<div class="one_line dispense_written col-md-6 col-12 d-flex justify-content-start align-items-center flex-column pl-1">
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-center">
<div class="d-block justify-content-start align-items-center px-2">
Substitution Permitted/Product Selection Permitted/Submission Permissible
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-between align-items-start">
<div class="d-flex justify-content-start col-md-8 col-sm-6 col-12 align-items-center px-2">
<div class="d-flex justify-content-between col-md-12 col-sm-12 col-12 align-items-center flex-column">
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center">
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center flex-column">
<label class="text-pink col-md-12 col-sm-12 col-12 txt13"><b>Prescriber Signature (substitution permitted)</b></label>
<div class="d-flex col-md-12 col-sm-12 col-12 justify-content-start align-items-center">
<img class="pat-sign-img" src="images/arrow.png" alt="">
<div class="signature_div">
<div class="mb-1"><a class="button" id="hcprovider_0_click_to_sign" href="#popup2" rel="modal:open">Click here to sign</a></div>
<div class="hcprovider_0_signed signed" style="display: none;">
<div class="sigWrapper">
<a href="#popup2" rel="modal:open"><div class="typed" id="hcprovider_0_typed"></div></a>
<a href="#popup2" rel="modal:open"><canvas class="pad" id="hcprovider_0_draw" width="198" height="55"></canvas></a>
</div>
</div>
<input type="hidden" name="prescription_info[signature_permitted]" id="hcprovider_0_signature_name" value="" />
<input type="hidden" name="prescription_info[signature_permitted]" id="hcprovider_0_signImageFile" value="" />
<div id="popup2" class="modal">
<div class="content">
<canvas id="signature-pad" class="signature-pad" width=198 height=55></canvas>
<!-- <div id="sig" style="width:50%; min-heght:50px;height: 235px;">
<div class="hcprovider_0_sigPad">
<label for="name" id="print_name">Print your name</label>
<input type="text" name="hcprovider[0][consent_name]" id="hcprovider_0_consent_name" class="name data" style="padding-left: 5px;">
<p class="typeItDesc">Review your signature</p>
<p class="drawItDesc">Draw your signature</p>
--> <ul class="sigNav">
<li class="typeIt"><a href="#type-it" class="current">Type It</a></li>
<li class="drawIt"><a id="save" href="#draw-it" >Draw It</a></li>
<li class="clearButton"><a id="clear" href="#clear">Clear</a></li>
</ul><!--
<div class="sig sigWrapper">
<div class="typed"></div>
<canvas class="pad" id="signature-pad-canvas" width="350" height="100"></canvas>
<input type="hidden" name="output" class="output">
</div>
<br />
<input type="button" id="hcprovider_0_save" value="Save" />
</div>
</div>-->
<textarea id="hcprovider_0_signature64" name="prescription_info[signature_permitted64]" style="display: none"></textarea>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-start col-md-4 col-sm-6 col-12 date_field align-items-center flex-column height-64">
<label class="text-pink col-md-12 col-sm-12 col-12 txt13"><b>Date:</b> </label>
<input class="form-control date-format local" name="prescription_info[substitution_consent_date]" type="date" id="substitution_consent_date" value="<?php echo!empty($saved_data['hcprovider']['substitution_consent_date']) ? $saved_data['hcprovider']['substitution_consent_date'] : ''; ?>">
</div>
</div>
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-start align-items-end">
<div class="col-md-9 col-sm-12 col-12 px-2">
<b>CA, MA, NC, & PR:</b> Interchange is mandated unless the prescriber writes the words <b>“No Substitution”</b>:
</div>
<div class="col-md-3 col-sm-12 col-12">
<input class="form-control" name="prescription_info[no_substitution]" type="text" id="prescription_info_no_substitution" value="<?php echo!empty($saved_data['prescription_info']['no_substitution']) ? $saved_data['prescription_info']['no_substitution'] : ''; ?>">
</div>
</div>
<div class="one_line col-md-12 col-12 d-flex justify-content-center align-items-center">
<button type="submit" class="btn bg-purple button_sub text-white" id="sub_btn" name="sub_btn">Submit</button>
</div>
</div>
</div>
</div>
</form>
</div>
<div class="tezspire_form px-4 bg-white page2">
<div class="section_eight">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-12 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex px-3 col-md-12 col-sm-12 col-12 header-title txt-8 text-pink align-items-center">AUTHORIZATION TO USE AND DISCLOSE PERSONAL INFORMATION</div>
</div>
</div>
<div class="d-flex col-md-12 col-sm-12 col-12 txt2 mb-2 flex-column p-2">
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
<strong>Uses and Disclosure of Personal Information</strong>
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
Please read the following carefully, then date and sign where indicated in section 1
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-2">
I authorize Amgen, AstraZeneca Pharmaceuticals LP, and their contractors and business partners (“Amgen and AstraZeneca”) to use and/or disclose
my personal information, including my personal health information, only for the following purposes:
</div>
<div class="col-md-12 col-sm-12 col-12 pt-2">
<ul>
<li>
To operate, administer, enroll me in, and/or continue my participation in Amgen and AstraZeneca’s TEZSPIRE<sup>TM</sup> Together program or any other
Amgen- and AstraZeneca-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs,
reimbursement assistance programs, drug coverage verification, nurse educator services, adherence program and disease management support);
</li>
<li>
To contact, with my permission, my doctor and the rest of my healthcare team and share with them my health information that may be useful for
my care;
</li>
<li>
To provide me with informational and promotional materials relating to Amgen and AstraZeneca products and services, and/or my condition or
treatment; and/or
</li>
<li>
To improve, develop, conduct, and evaluate products, services, materials, outcomes/scientific research, and programs related to my condition or
treatment
</li>
<li>
Outcomes/Scientific research purposes which includes contacting me to participate in focus groups, surveys, research, or interviews. In order for
Amgen and AstraZeneca to provide me with the services and/or programs described above, Amgen and AstraZeneca need to collect and use my
personal information, including my personal health information. I understand that my personal health information may include any information,
in electronic or physical form, in the possession of or derived from a healthcare provider, healthcare plan, pharmacy, pharmaceutical company,
laboratory, and/or their contractor (“Healthcare Provider”). This may include select information from or about my medical history and general health,
my healthcare plan benefits, payment limits or restrictions covered by my healthcare plan policy, and/or my adherence to my treatment.
</li>
</ul>
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center">
I authorize my Healthcare Providers to disclose my personal health information to Amgen and AstraZeneca, and between themselves, as necessary,
but only for the purposes stated above in this Authorization. I understand that certain of my Healthcare Providers (such as pharmacies and specialty
pharmacies) may receive remuneration from Amgen and AstraZeneca in exchange for disclosing my personal health information and/or for using my
information to contact me with communications about Amgen and AstraZeneca products which have been prescribed to me (for example, medication
reminder programs) and other patient support services.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
Expiration, Right to Obtain a Copy, and Right to Cancel
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
I understand that by signing this form, I authorize my Healthcare Providers or others who might hold my health information to only release it to Amgen
and AstraZeneca employees, as well as to their contractors and business partners, who are performing the services set forth in this Authorization. I
also understand I am authorizing my personal information, including my personal health information, to be used for the purposes described above. I
understand and agree that by signing below, I am authorizing those who rely on this Authorization to release my personal health information for the
earlier of five (5) years or until my participation in the program ends through my cancellation, unless a shorter time period is required by state law.
<br>
<br>
I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling 1-888-TZSPIRE (1-888-897-7473) or by
writing to Cardinal Health Specialty Solutions, 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067. If I cancel my consent, I will no longer qualify for
the services described. I also understand that if a Healthcare Provider is disclosing my personal health information to Amgen and AstraZeneca on an
authorized on-going basis, my cancellation with Amgen and AstraZeneca will be effective with respect to any such Healthcare Providers as soon as
they receive notice of my cancellation.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
No Effect on Treatment
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely
voluntary. I understand that Amgen and AstraZeneca, as well as Healthcare Providers, cannot require me, as a condition of having access to
medications, prescription drugs, treatment, or other care, to sign this Authorization. Federal law (including HIPAA) requires a signed authorization in
order for Amgen and AstraZeneca to collect this information from my Healthcare Providers. I understand I cannot participate in the listed services
and/or programs without signing this Authorization or an equivalent authorization with my Healthcare Providers.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
Information Received From Healthcare Providers
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
I understand that once my personal health information has been disclosed to Amgen and AstraZeneca, federal privacy laws may no longer apply and
protect it from further disclosure. Amgen and AstraZeneca agree, however, to protect my personal health information by only using and disclosing it as
stated in the Authorization or as otherwise allowed or required by law.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
Authorization to Contact
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
I understand and consent to Amgen and AstraZeneca contacting me using the contact information provided in this form to enroll me in, operate,
and administer Amgen and AstraZeneca patient support services and/or programs as described above other than promotional communications by
telephone or SMS/text. I understand that the operation and administration of certain of these services and/or programs may require that Amgen and
AstraZeneca contact me by telephone or SMS/text.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center text-purple txt8 pt-2">
Safety Reporting Follow-up
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
I understand that for safety reporting purposes, the safety department of AstraZeneca or its trusted processors may contact me for follow-up for the
reporting of any adverse events or other safety findings.
</div>
</div>
</div>
</div>
<div class="tezspire_form px-4 bg-white page3">
<div class="section_eight mb-2">
<div class="title_image d-flex col-md-12 col-12 align-items-start">
<div class="d-flex col-md-12 col-sm-12 col-12 align-items-start txt-11">
<div class="d-flex px-3 col-md-12 col-sm-12 col-12 header-title txt-8 text-pink align-items-center">FAST START PROGRAM TERMS & CONDITIONS</div>
</div>
</div>
<div class="d-flex col-md-12 col-sm-12 col-12 txt2 mb-2 flex-column p-2">
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-1">
The TEZSPIRE™ Together Fast Start Program is available to patients who have been prescribed TEZSPIRE and
who have commercial or private insurance, including state and federal plans commonly referred to as
“healthcare exchange plans.” This program helps eligible patients obtain TEZSPIRE while coverage is being secured,
up to program limits.
<br>
<br>
This offer is not valid if patient is uninsured or receiving prescription reimbursement under any federal-, state-,
or government-funded healthcare program, such as Medicare, Medicare Advantage, Medicare Part D, the Retiree Drug
Subsidy Program, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or TRICARE or where
prohibited by law. It is not valid for cash-paying or uninsured patients. Cash Discount Cards and other noninsurance
plans are not valid as primary under this offer. If at any time patient begins receiving coverage under any such
federal-, state-, or government-funded healthcare program, patient will no longer be able to use this offer and
patient must call 1-888-TZSPIRE (1-888-897-7473) to stop participation. By participating in this offer, patient
acknowledges intent to pursue insurance coverage for TEZSPIRE with their healthcare provider. Once insurance approval
is obtained, patient is no longer eligible for this offer. No purchase necessary. This is not health insurance.
Participation is not a guarantee of insurance coverage. Offer is not renewable. This offer is only valid in the
United States, Puerto Rico, and the US territories. Other restrictions may apply. This offer is subject to change
or discontinuation without notice.
</div>
<div class="col-md-12 col-sm-12 col-12 pt-2">
<ul>
<li>
If the patient’s health plan does not cover TEZSPIRE or requires a prior authorization, patient can
receive TEZSPIRE free for up to twelve (12) doses within twenty-four (24) months from the date the first
dose is shipped under the Fast Start Program.
</li>
<li>
Ongoing eligibility after the first 60 days requires that the prior authorization (PA) is submitted by the provider.
If the PA is not submitted within 60 days of the first shipment, then patient will no longer be eligible for the
Fast Start Program.
</li>
<li>
If the PA results in a denial, the provider must submit the appeal within 60 days of the denial. If the appeal
is not submitted within 60 days of the denial, then patient will no longer be eligible for the Fast Start Program.
</li>
</ul>
</div>
</div>
</div>
</div>
<div class="tezspire_form px-4 bg-white page2">
<div class="section_eight">
<div class="d-flex col-md-12 col-sm-12 col-12 txt10 mb-2 flex-column p-2">
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt8 pt-3">
INDICATION
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center">
TEZSPIRE is indicated for the add-on maintenance treatment of adult and pediatric patients aged 12 years and older with severe asthma.<br>
TEZSPIRE is not indicated for the relief of acute bronchospasm or status asthmaticus.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt9 pt-3">
IMPORTANT SAFETY INFORMATION
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt8 pt-3">
CONTRAINDICATIONS
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center">
Known hypersensitivity to tezepelumab-ekko or excipients.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt8 pt-3">
WARNINGS & PRECAUTIONS
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start flex-column">
<strong>Hypersensitivity Reactions</strong><br>
Hypersensitivity reactions (e.g., rash and allergic conjunctivitis) can occur following administration of TEZSPIRE. These
reactions can occur within hours of administration, but in some instances have a delayed onset (i.e., days). In the event
of a hypersensitivity reaction, initiate appropriate treatment as clinically indicated and then consider the benefits and
risks for the individual patient to determine whether to continue or discontinue treatment with TEZSPIRE.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start flex-column pt-3">
<strong>Acute Asthma Symptoms or Deteriorating Disease</strong><br>
TEZSPIRE should not be used to treat acute asthma symptoms, acute exacerbations, acute bronchospasm, or status
asthmaticus.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start flex-column pt-3">
<strong>Abrupt Reduction of Corticosteroid Dosage</strong><br>
Do not discontinue systemic or inhaled corticosteroids abruptly upon initiation of therapy with TEZSPIRE. Reductions
in corticosteroid dose, if appropriate, should be gradual and performed under the direct supervision of a physician.
Reduction in corticosteroid dose may be associated with systemic withdrawal symptoms and/or unmask conditions
previously suppressed by systemic corticosteroid therapy.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start flex-column pt-3">
<strong>Parasitic (Helminth) Infection</strong><br>
It is unknown if TEZSPIRE will influence a patient’s response against helminth infections. Treat patients with pre-existing
helminth infections before initiating therapy with TEZSPIRE. If patients become infected while receiving TEZSPIRE and
do not respond to anti-helminth treatment, discontinue TEZSPIRE until infection resolves.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start flex-column pt-3">
<strong>Live Attenuated Vaccines</strong><br>
The concomitant use of TEZSPIRE and live attenuated vaccines has not been evaluated. The use of live attenuated
vaccines should be avoided in patients receiving TEZSPIRE.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt8 pt-3">
ADVERSE REACTIONS
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-3">
The most common adverse reactions (incidence ≥3%) are pharyngitis, arthralgia, and back pain.
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center txt8 pt-3">
USE IN SPECIFIC POPULATIONS
</div>
<div class="col-md-12 col-sm-12 col-12 d-flex justify-content-start align-items-center pt-3">
There are no available data on TEZSPIRE use in pregnant women to evaluate for any drug-associated risk of major birth
defects, miscarriage, or other adverse maternal or fetal outcomes. Placental transfer of monoclonal antibodies such as
tezepelumab-ekko is greater during the third trimester of pregnancy; therefore, potential effects on a fetus are likely to
be greater during the third trimester of pregnancy.
</div>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex p-2 text-purple justify-content-start align-items-start txt13 text-left flex-column">
<strong>Full <a class="txt13 text-purple" href="https://www.pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/tezspire/tezspire_pi_hcp_english.ashx" target="_blank">Prescribing Information</a> including <a class="txt13 text-purple" href="https://www.pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/tezspire/tezspire_ppi_pt_english.ashx" target="_blank">Patient Information</a></strong><br>
<i>You may report side effects related to AstraZeneca products by clicking <a class="txt13 text-dark" href="https://us-aereporting.astrazeneca.com/adverse-events.html" target="_blank">here.</a></i>
</div>
<div class="one_line col-md-12 col-sm-12 col-12 text-center justify-content-start align-items-center p-4 txt10 text-purple">
<strong>Patient or legal representative:</strong> visit <strong>TEZSPIRETogether.com</strong> or call <strong>1-888-TZSPIRE (1-888-897-7473)</strong><br>
to enroll in the TEZSPIRE Together Co-pay Program (for eligible commercially insured patients only) or to see if you may be eligible for other financial support.
</div>
</div>
</div>
<div class="tezspire_form px-4 bg-white footer">
<div class="section_footer_logo d-flex col-md-12 col-12 align-items-start justify-content-between p-2 mb-3 flex-column">
<div class="d-flex d-flex-mobile justify-content-start align-items-baseline col-md-3 col-sm-12 col-12">
<img class="footer_logo_img amgen_logo" src="images/amgen.png" alt="">
<img class="footer_logo_img" src="images/astra.png" alt="">
</div>
<div class="one_line col-md-12 col-sm-12 col-12 d-flex justify-content-between align-items-center txt5">
<span>©2021 Amgen Inc and AstraZeneca. All rights reserved.</span>
<span>USA-157-80204 10/21</span>
</div>
</div>
</div>
</div>
</div>
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cancelButton.addEventListener('click', function (event) {
signaturePad.clear();
});
</script>
<script src="https://cdn.jsdelivr.net/jquery.validation/1.16.0/jquery.validate.min.js"></script>
<script>
$(document).ready(function () {
$('#enroll_form').validate({
rules: {
fname: {
required: true
},
email: {
required: true,
email: true
},
phone: {
required: true,
digits: true
}
},
errorElement: 'span',
errorPlacement: function (error, element) {
// error.addClass('invalid-feedback');
// element.closest('.form-group').append(error);
},
highlight: function (element, errorClass, validClass) {
$(element).addClass('is-invalid');
},
unhighlight: function (element, errorClass, validClass) {
$(element).removeClass('is-invalid');
}
});
});
</script>
</html>