{"id":238,"date":"2023-01-03T22:20:53","date_gmt":"2023-01-03T22:20:53","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=238"},"modified":"2023-01-03T22:24:33","modified_gmt":"2023-01-03T22:24:33","slug":"txconnect-referral-portal-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/txconnect-referral-portal-form\/","title":{"rendered":"TxConnect Referral Portal Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_44' style='display:none'><div id='gf_44' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_44' id='gform_44'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/238#gf_44' novalidate>\n                        <div class='gform_body gform-body'><ul id='gform_fields_44' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_44_1\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_44_1'>\n                            \n                            <span id='input_44_1_3_container' class='name_first' >\n                                                    <input type='text' name='input_1.3' id='input_44_1_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_44_1_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_1_6_container' class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_44_1_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_44_1_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_44_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_2' >Work Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_44_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_44_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_3' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_44_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_44_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_4' >Dialysis Center(s) or Nephrology Practice(s) You Cover<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_44_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_42' >Dialysis Center Medicare #<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_44_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Dialysis Center Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_44_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_44_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_44_6_1' value=''    aria-required='false'    \/>\n                                        <label for='input_44_6_1' id='input_44_6_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_44_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_44_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_44_6_2' id='input_44_6_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_44_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_44_6_3' value=''    aria-required='false'    \/>\n                                    <label for='input_44_6_3' id='input_44_6_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_44_6_4_container' >\n                                        <select name='input_6.4' id='input_44_6_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_44_6_4' id='input_44_6_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_44_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_44_6_5' value=''    aria-required='false'    \/>\n                                    <label for='input_44_6_5' id='input_44_6_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_44_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_44_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Select &quot;Yes&quot; if you need to add more Dialysis Centers<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_44_26'>\n\t\t\t<li class='gchoice gchoice_44_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_44_26_0'    \/>\n\t\t\t\t<label for='choice_44_26_0' id='label_44_26_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_44_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_44_26_1'    \/>\n\t\t\t\t<label for='choice_44_26_1' id='label_44_26_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_44_11\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_11' >Dialysis Center(s) You Cover<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_44_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_43\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_43' >Dialysis Center Medicare #<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_44_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_31\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_31' >Dialysis Center(s) You Cover<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_44_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_44\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_44' >Dialysis Center Medicare #<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_44_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_30' >Dialysis Center(s) You Cover<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_44_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_45\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_45' >Dialysis Center Medicare #<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_44_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_29\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_29' >Dialysis Center(s) You Cover<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_44_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_44_46' >Dialysis Center Medicare #<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_44_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_44_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_7'>\n                            \n                            <span id='input_44_7_3_container' class='name_first' >\n                                                    <input type='text' name='input_7.3' id='input_44_7_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_44_7_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_7_6_container' class='name_last' >\n                                                    <input type='text' name='input_7.6' id='input_44_7_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_44_7_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_7_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_7.8' id='input_44_7_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_7_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_8\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >MD Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_44_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_44_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_44_8_1' value=''    aria-required='false'    \/>\n                                        <label for='input_44_8_1' id='input_44_8_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_44_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_44_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_44_8_2' id='input_44_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_44_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_44_8_3' value=''    aria-required='false'    \/>\n                                    <label for='input_44_8_3' id='input_44_8_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_44_8_4_container' >\n                                        <select name='input_8.4' id='input_44_8_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_44_8_4' id='input_44_8_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_44_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_44_8_5' value=''    aria-required='false'    \/>\n                                    <label for='input_44_8_5' id='input_44_8_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_44_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_44_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Select &quot;Yes&quot; if you need to add more doctors you work with.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_44_32'>\n\t\t\t<li class='gchoice gchoice_44_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_44_32_0'    \/>\n\t\t\t\t<label for='choice_44_32_0' id='label_44_32_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_44_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_44_32_1'    \/>\n\t\t\t\t<label for='choice_44_32_1' id='label_44_32_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_44_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_37'>\n                            \n                            <span id='input_44_37_3_container' class='name_first' >\n                                                    <input type='text' name='input_37.3' id='input_44_37_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_37_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_37_6_container' class='name_last' >\n                                                    <input type='text' name='input_37.6' id='input_44_37_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_37_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_37_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_37.8' id='input_44_37_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_37_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_55\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_55'>\n                            \n                            <span id='input_44_55_3_container' class='name_first' >\n                                                    <input type='text' name='input_55.3' id='input_44_55_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_55_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_55_6_container' class='name_last' >\n                                                    <input type='text' name='input_55.6' id='input_44_55_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_55_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_55_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_55.8' id='input_44_55_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_55_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_54'>\n                            \n                            <span id='input_44_54_3_container' class='name_first' >\n                                                    <input type='text' name='input_54.3' id='input_44_54_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_54_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_54_6_container' class='name_last' >\n                                                    <input type='text' name='input_54.6' id='input_44_54_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_54_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_54_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_54.8' id='input_44_54_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_54_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_53\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_53'>\n                            \n                            <span id='input_44_53_3_container' class='name_first' >\n                                                    <input type='text' name='input_53.3' id='input_44_53_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_53_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_53_6_container' class='name_last' >\n                                                    <input type='text' name='input_53.6' id='input_44_53_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_53_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_53_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_53.8' id='input_44_53_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_53_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_52'>\n                            \n                            <span id='input_44_52_3_container' class='name_first' >\n                                                    <input type='text' name='input_52.3' id='input_44_52_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_52_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_52_6_container' class='name_last' >\n                                                    <input type='text' name='input_52.6' id='input_44_52_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_52_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_52_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_52.8' id='input_44_52_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_52_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_51\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_51'>\n                            \n                            <span id='input_44_51_3_container' class='name_first' >\n                                                    <input type='text' name='input_51.3' id='input_44_51_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_51_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_51_6_container' class='name_last' >\n                                                    <input type='text' name='input_51.6' id='input_44_51_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_51_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_51_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_51.8' id='input_44_51_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_51_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_50'>\n                            \n                            <span id='input_44_50_3_container' class='name_first' >\n                                                    <input type='text' name='input_50.3' id='input_44_50_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_50_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_50_6_container' class='name_last' >\n                                                    <input type='text' name='input_50.6' id='input_44_50_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_50_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_50_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_50.8' id='input_44_50_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_50_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_47\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_47'>\n                            \n                            <span id='input_44_47_3_container' class='name_first' >\n                                                    <input type='text' name='input_47.3' id='input_44_47_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_47_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_47_6_container' class='name_last' >\n                                                    <input type='text' name='input_47.6' id='input_44_47_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_47_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_47_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_47.8' id='input_44_47_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_47_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_49\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_49'>\n                            \n                            <span id='input_44_49_3_container' class='name_first' >\n                                                    <input type='text' name='input_49.3' id='input_44_49_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_49_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_49_6_container' class='name_last' >\n                                                    <input type='text' name='input_49.6' id='input_44_49_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_49_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_49_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_49.8' id='input_44_49_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_49_8' >NPI<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_44_48\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Doctor(s) You Work With<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name' id='input_44_48'>\n                            \n                            <span id='input_44_48_3_container' class='name_first' >\n                                                    <input type='text' name='input_48.3' id='input_44_48_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_44_48_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_44_48_6_container' class='name_last' >\n                                                    <input type='text' name='input_48.6' id='input_44_48_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_44_48_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_44_48_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_48.8' id='input_44_48_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_44_48_8' >NPI<\/label>\n                                                <\/span>\n                        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