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#e6e6e6;\n}\n.form-matrix-table tr {\n  border-color: #e6e6e6;\n}\n.form-matrix-table tr:nth-child(2n) {\n  background-color: #f2f2f2;\n}\n.form-all {\n  color: #555555;\n}\n.form-header-group .form-header {\n  color: #555555;\n}\n.form-header-group .form-subHeader {\n  color: #6f6f6f;\n}\n.form-sub-label {\n  color: #6f6f6f;\n}\n.form-label-top,\n.form-label-left,\n.form-label-right,\n.form-html {\n  color: #555555;\n}\n.form-checkbox-item label,\n.form-radio-item label {\n  color: #6f6f6f;\n}\n.form-line.form-line-active {\n  -webkit-transition-property: all;\n  -moz-transition-property: all;\n  -ms-transition-property: all;\n  -o-transition-property: all;\n  transition-property: all;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #ffffe0;\n}\n\/* omer *\/\n.form-radio-item,\n.form-checkbox-item {\n  padding-bottom: 0px !important;\n}\n.form-radio-item:last-child,\n.form-checkbox-item:last-child {\n  padding-bottom: 0;\n}\n\/* omer *\/\n[data-type=\"control_radio\"] .form-input,\n[data-type=\"control_checkbox\"] .form-input,\n[data-type=\"control_radio\"] .form-input-wide,\n[data-type=\"control_checkbox\"] .form-input-wide {\n  width: 100%;\n  max-width: 350px;\n}\n.form-radio-item,\n.form-checkbox-item {\n  width: 100%;\n  max-width: 350px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-textbox.form-radio-other-input,\n.form-textbox.form-checkbox-other-input {\n  width: 80%;\n  margin-left: 3%;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-multiple-column {\n  width: 100%;\n}\n.form-multiple-column .form-radio-item,\n.form-multiple-column .form-checkbox-item {\n  width: 10%;\n}\n.form-multiple-column[data-columncount=\"1\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"1\"] .form-checkbox-item {\n  width: 100%;\n}\n.form-multiple-column[data-columncount=\"2\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"2\"] .form-checkbox-item {\n  width: 50%;\n}\n.form-multiple-column[data-columncount=\"3\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"3\"] .form-checkbox-item {\n  width: 33.33333333%;\n}\n.form-multiple-column[data-columncount=\"4\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"4\"] .form-checkbox-item {\n  width: 25%;\n}\n.form-multiple-column[data-columncount=\"5\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"5\"] .form-checkbox-item {\n  width: 20%;\n}\n.form-multiple-column[data-columncount=\"6\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"6\"] .form-checkbox-item {\n  width: 16.66666667%;\n}\n.form-multiple-column[data-columncount=\"7\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"7\"] .form-checkbox-item {\n  width: 14.28571429%;\n}\n.form-multiple-column[data-columncount=\"8\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"8\"] .form-checkbox-item {\n  width: 12.5%;\n}\n.form-multiple-column[data-columncount=\"9\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"9\"] .form-checkbox-item {\n  width: 11.11111111%;\n}\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.form-checkbox-item .editor-container div,\n.form-radio-item .editor-container div {\n  position: relative;\n}\n.form-checkbox-item .editor-container div:before,\n.form-radio-item .editor-container div:before {\n  display: inline-block;\n  vertical-align: middle;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  left: 0;\n  width: 18px;\n  height: 18px;\n}\n.form-radio-item:not(#foo) {\n  position: relative;\n}\n.form-radio-item:not(#foo) .form-radio-other.form-radio {\n  display: none !important;\n}\n.form-radio-item:not(#foo) input[type=\"checkbox\"],\n.form-radio-item:not(#foo) input[type=\"radio\"] {\n  display: none;\n}\n.form-radio-item:not(#foo) .form-radio-other,\n.form-radio-item:not(#foo) .form-checkbox-other {\n  display: inline-block !important;\n  margin-left: 17px;\n  margin-right: 13px;\n  margin-top: 0px;\n}\n.form-radio-item:not(#foo) .form-checkbox-other-input,\n.form-radio-item:not(#foo) .form-radio-other-input {\n  margin: 0;\n}\n.form-radio-item:not(#foo) label {\n  line-height: 18px;\n  float: left;\n  margin-left: 37px;\n}\n.form-radio-item:not(#foo) label:before {\n  content: '';\n  position: absolute;\n  display: inline-block;\n  vertical-align: baseline;\n  margin-right: 4px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  -webkit-border-radius: 2px;\n  -moz-border-radius: 2px;\n  border-radius: 2px;\n  left: 4px;\n  width: 18px;\n  height: 18px;\n  cursor: pointer;\n}\n.form-radio-item:not(#foo) label:after {\n  content: '';\n  position: absolute;\n  z-index: 10;\n  display: inline-block;\n  opacity: 0;\n  top: 4px;\n  left: 8px;\n  width: 10px;\n  height: 10px;\n}\n.form-radio-item:not(#foo) input:checked + label:after {\n  opacity: 1;\n}\n.form-radio-item:not(#foo) label:before {\n  background-color: transparent;\n  border: 2px solid #828282;\n}\n.form-radio-item:not(#foo) .editor-container div:before {\n  content: '';\n  background-color: transparent;\n  border: 2px solid #828282;\n  margin: 0 4px 0 -6px;\n}\n.form-radio-item:not(#foo) label:after {\n  background-color: #0977ec;\n  cursor: pointer;\n}\n.form-checkbox-item:not(#foo) {\n  position: relative;\n}\n.form-checkbox-item:not(#foo) .form-checkbox-other.form-checkbox {\n  display: none !important;\n}\n.form-checkbox-item:not(#foo) input[type=\"checkbox\"],\n.form-checkbox-item:not(#foo) input[type=\"radio\"] {\n  display: none;\n}\n.form-checkbox-item:not(#foo) .form-radio-other,\n.form-checkbox-item:not(#foo) .form-checkbox-other {\n  display: inline-block !important;\n  margin-left: 17px;\n  margin-right: 13px;\n  margin-top: 0px;\n}\n.form-checkbox-item:not(#foo) .form-checkbox-other-input,\n.form-checkbox-item:not(#foo) .form-radio-other-input {\n  margin: 0;\n}\n.form-checkbox-item:not(#foo) label {\n  line-height: 18px;\n  float: left;\n  margin-left: 37px;\n}\n.form-checkbox-item:not(#foo) label:before {\n  content: '';\n  position: absolute;\n  display: inline-block;\n  vertical-align: baseline;\n  margin-right: 4px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  -webkit-border-radius: 2px;\n  -moz-border-radius: 2px;\n  border-radius: 2px;\n  left: 4px;\n  width: 18px;\n  height: 18px;\n  cursor: pointer;\n}\n.form-checkbox-item:not(#foo) label:after {\n  content: '';\n  position: absolute;\n  z-index: 10;\n  display: inline-block;\n  opacity: 0;\n  top: 6px;\n  left: 10px;\n  width: 4px;\n  height: 4px;\n}\n.form-checkbox-item:not(#foo) input:checked + label:after {\n  opacity: 1;\n}\n.form-checkbox-item:not(#foo) label:before {\n  background-color: transparent;\n  border: 2px solid #828282;\n}\n.form-checkbox-item:not(#foo) .editor-container div:before {\n  content: '';\n  background-color: transparent;\n  border: 2px solid #828282;\n  margin: 0 4px 0 -6px;\n}\n.form-checkbox-item:not(#foo) label:after {\n  background-color: #0977ec;\n  box-shadow: 0 3px 0 0 #0977ec, 3px 3px 0 0 #0977ec, 6px 3px 0 0 #0977ec, 9px 3px 0 0 #0977ec, 8px 6px 0 0 #ffffff, 10px 1px 0 0 #ffffff;\n  -moz-transform: rotate(-45deg);\n  -webkit-transform: rotate(-45deg);\n  -o-transform: rotate(-45deg);\n  -ms-transform: rotate(-45deg);\n  transform: rotate(-45deg);\n}\n.supernova {\n  height: 100%;\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.supernova {\n  background-image: none;\n}\n#stage {\n  background-image: none;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.form-line {\n  margin-top: 0px;\n  margin-bottom: 0px;\n}\n.form-line {\n  padding: 12px 36px;\n}\n.form-all .form-textbox,\n.form-all .form-radio-other-input,\n.form-all .form-checkbox-other-input,\n.form-all .form-captcha input,\n.form-all .form-spinner input,\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next,\n.form-all .qq-upload-button,\n.form-all .form-error-message {\n  -webkit-border-radius: 6px;\n  -moz-border-radius: 6px;\n  border-radius: 6px;\n}\n.form-all .form-sub-label {\n  margin-left: 3px;\n}\n.form-all .form-textarea {\n  -webkit-border-radius: 6px;\n  -moz-border-radius: 6px;\n  border-radius: 6px;\n}\n.form-dropdown {\n  -webkit-border-radius: 6px;\n  -moz-border-radius: 6px;\n  border-radius: 6px;\n  -webkit-appearance: none;\n  -moz-appearance: button;\n  appearance: none;\n  margin: 0;\n}\n.form-all {\n  -webkit-border-radius: 6px;\n  -moz-border-radius: 6px;\n  border-radius: 6px;\n}\n.form-section:first-child {\n  -webkit-border-radius: 6px 6px 0 0;\n  -moz-border-radius: 6px 6px 0 0;\n  border-radius: 6px 6px 0 0;\n}\n.form-section:last-child {\n  -webkit-border-radius: 0 0 6px 6px;\n  -moz-border-radius: 0 0 6px 6px;\n  border-radius: 0 0 6px 6px;\n}\n.form-all .qq-upload-button,\n.form-all .form-submit-button,\n.form-all .form-submit-reset,\n.form-all .form-submit-print {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Verdana\", sans-serif;\n  font-size: 16px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Verdana\", sans-serif;\n  font-size: 16px;\n  font-weight: normal;\n}\n\/*\n& when ( @buttonFontType = google ) {\n\t@import (css) \"@{buttonFontLink}\";\n}\n*\/\nh2.form-header {\n  line-height: 1.618em;\n  font-size: 1.714em;\n}\nh2 ~ .form-subHeader {\n  line-height: 1.5em;\n  font-size: 1.071em;\n}\n.form-header-group {\n  text-align: left;\n}\n.form-line {\n  zoom: 1;\n}\n.form-line:before,\n.form-line:after {\n  display: table;\n  content: '';\n  line-height: 0;\n}\n.form-line:after {\n  clear: both;\n}\n.form-captcha input,\n.form-spinner input {\n  width: 350px;\n}\n.form-textbox,\n.form-textarea {\n  width: 100%;\n  max-width: 350px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-input,\n.form-address-table,\n.form-matrix-table {\n  width: 100%;\n  max-width: 350px;\n}\n.form-radio-item,\n.form-checkbox-item {\n  width: 100%;\n  max-width: 350px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-textbox.form-radio-other-input,\n.form-textbox.form-checkbox-other-input {\n  width: 80%;\n  margin-left: 3%;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-multiple-column {\n  width: 100%;\n}\n.form-multiple-column .form-radio-item,\n.form-multiple-column .form-checkbox-item {\n  width: 10%;\n}\n.form-multiple-column[data-columncount=\"1\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"1\"] .form-checkbox-item {\n  width: 100%;\n}\n.form-multiple-column[data-columncount=\"2\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"2\"] .form-checkbox-item {\n  width: 50%;\n}\n.form-multiple-column[data-columncount=\"3\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"3\"] .form-checkbox-item {\n  width: 33.33333333%;\n}\n.form-multiple-column[data-columncount=\"4\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"4\"] .form-checkbox-item {\n  width: 25%;\n}\n.form-multiple-column[data-columncount=\"5\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"5\"] .form-checkbox-item {\n  width: 20%;\n}\n.form-multiple-column[data-columncount=\"6\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"6\"] .form-checkbox-item {\n  width: 16.66666667%;\n}\n.form-multiple-column[data-columncount=\"7\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"7\"] .form-checkbox-item {\n  width: 14.28571429%;\n}\n.form-multiple-column[data-columncount=\"8\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"8\"] .form-checkbox-item {\n  width: 12.5%;\n}\n.form-multiple-column[data-columncount=\"9\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"9\"] .form-checkbox-item {\n  width: 11.11111111%;\n}\n[data-type=\"control_dropdown\"] .form-dropdown {\n  width: 100% !important;\n  max-width: 350px;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container {\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  width: 48%;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container:first-child {\n  margin-right: 4%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container {\n  width: 62.5%;\n  margin-left: 2.5%;\n  margin-right: 0;\n  float: left;\n  position: relative;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child {\n  width: 32.5%;\n  margin-right: 2.5%;\n  margin-left: 0;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child [data-component=areaCode] {\n  width: 93%;\n  float: left;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child [data-component=areaCode] ~ .form-sub-label {\n  display: inline-block;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child .phone-separate {\n  position: absolute;\n  top: 0;\n  right: -16%;\n  width: 24%;\n  text-align: center;\n  text-indent: -4px;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container {\n  width: 22%;\n  margin-right: 3%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:first-child {\n  width: 50%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:last-child {\n  margin-right: 0;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n[data-type=\"control_payment\"] .form-sub-label-container {\n  width: auto;\n}\n[data-type=\"control_payment\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-sub-label-container {\n  width: 96%;\n}\n.form-address-table td:last-child .form-sub-label-container {\n  margin-left: 4%;\n}\n.form-address-table td[colspan=\"2\"] .form-sub-label-container {\n  width: 100%;\n  margin: 0;\n}\n\/*.form-dropdown,\n.form-radio-item,\n.form-checkbox-item,\n.form-radio-other-input,\n.form-checkbox-other-input,*\/\n.form-captcha input,\n.form-spinner input,\n.form-error-message {\n  padding: 4px 3px 2px 3px;\n}\n.form-header-group {\n  font-family: \"Verdana\", sans-serif;\n}\n.form-section {\n  padding: 0px 0px 0px 0px;\n}\n.form-header-group {\n  margin: 12px 36px 12px 36px;\n}\n.form-header-group {\n  padding: 24px 0px 24px 0px;\n}\n.form-textbox,\n.form-textarea {\n  padding: 4px 3px 2px 3px;\n}\n.form-textbox,\n.form-textarea,\n.form-radio-other-input,\n.form-checkbox-other-input,\n.form-captcha input,\n.form-spinner input {\n  background-color: #ffffff;\n}\n.form-textbox {\n  height: 40px;\n}\n.form-textarea {\n  height: 100px;\n}\n.form-textbox,\n.form-textarea {\n  width: 100%;\n  max-width: 350px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n[data-type=\"control_textbox\"] .form-input,\n[data-type=\"control_textarea\"] .form-input,\n[data-type=\"control_fullname\"] .form-input,\n[data-type=\"control_phone\"] .form-input,\n[data-type=\"control_datetime\"] .form-input,\n[data-type=\"control_address\"] .form-input,\n[data-type=\"control_email\"] .form-input,\n[data-type=\"control_passwordbox\"] .form-input,\n[data-type=\"control_autocomp\"] .form-input,\n[data-type=\"control_textbox\"] .form-input-wide,\n[data-type=\"control_textarea\"] .form-input-wide,\n[data-type=\"control_fullname\"] .form-input-wide,\n[data-type=\"control_phone\"] .form-input-wide,\n[data-type=\"control_datetime\"] .form-input-wide,\n[data-type=\"control_address\"] .form-input-wide,\n[data-type=\"control_email\"] .form-input-wide,\n[data-type=\"control_passwordbox\"] .form-input-wide,\n[data-type=\"control_autocomp\"] .form-input-wide {\n  width: 100%;\n  max-width: 350px;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container {\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  width: 48%;\n  margin-right: 0;\n  float: left;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container:first-child {\n  margin-right: 4%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container {\n  width: 62.5%;\n  margin-left: 2.5%;\n  margin-right: 0;\n  float: left;\n  position: relative;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child {\n  width: 32.5%;\n  margin-right: 2.5%;\n  margin-left: 0;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child [data-component=areaCode] {\n  width: 93%;\n  float: left;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child [data-component=areaCode] ~ .form-sub-label {\n  display: inline-block;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child .phone-separate {\n  position: absolute;\n  top: 0;\n  right: -16%;\n  width: 24%;\n  text-align: center;\n  text-indent: -4px;\n}\n[data-type=\"control_phone\"] .form-sub-label-container .date-separate {\n  visibility: hidden;\n}\n.form-matrix-table {\n  width: 100%;\n  max-width: 350px;\n}\n.form-address-table {\n  width: 100%;\n  max-width: 350px;\n}\n.form-address-table td .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-sub-label-container {\n  width: 96%;\n}\n.form-address-table td:last-child .form-sub-label-container {\n  margin-left: 4%;\n}\n.form-address-table td[colspan=\"2\"] .form-sub-label-container {\n  width: 100%;\n  margin: 0;\n}\n.form-dropdown {\n  -webkit-appearance: menulist-button;\n  height: 40px;\n}\n[data-type=\"control_dropdown\"] .form-input,\n[data-type=\"control_birthdate\"] .form-input,\n[data-type=\"control_time\"] .form-input,\n[data-type=\"control_dropdown\"] .form-input-wide,\n[data-type=\"control_birthdate\"] .form-input-wide,\n[data-type=\"control_time\"] .form-input-wide {\n  width: 100%;\n  max-width: 350px;\n}\n[data-type=\"control_dropdown\"] .form-dropdown {\n  width: 100% !important;\n  max-width: 350px;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container {\n  width: 22%;\n  margin-right: 3%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:first-child {\n  width: 50%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:last-child {\n  margin-right: 0;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n.form-label {\n  margin-right: 15px;\n  margin-bottom: 0;\n}\n.form-label {\n  font-family: \"Verdana\", sans-serif;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.form-line-column {\n  width: auto;\n}\n.form-line-error {\n  overflow: hidden;\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #fff4f4;\n}\n.form-line-error .form-error-message {\n  background-color: #ff3200;\n  clear: both;\n  float: none;\n}\n.form-line-error .form-error-message .form-error-arrow {\n  border-bottom-color: #ff3200;\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  border: 1px solid #ff3200;\n  -webkit-box-shadow: 0 0 3px #ff3200;\n  -moz-box-shadow: 0 0 3px #ff3200;\n  box-shadow: 0 0 3px #ff3200;\n}\n.ie-8 .form-all {\n  margin-top: auto;\n  margin-top: initial;\n}\n.ie-8 .form-all:before {\n  display: none;\n}\n[data-type=\"control_clear\"] {\n  display: none;\n}\n\/* | *\/\n@media screen and (max-width: 480px), screen and (max-device-width: 767px) and (orientation: portrait), screen and (max-device-width: 415px) and (orientation: landscape) {\n  .testOne {\n    letter-spacing: 0;\n  }\n  .form-all {\n    border: 0;\n    max-width: initial;\n  }\n  .form-sub-label-container {\n    width: 100%;\n    margin: 0;\n    margin-right: 0;\n    float: left;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  span.form-sub-label-container + span.form-sub-label-container {\n    margin-right: 0;\n  }\n  .form-sub-label {\n    white-space: normal;\n  }\n  .form-address-table td,\n  .form-address-table th {\n    padding: 0 1px 10px;\n  }\n  .form-submit-button,\n  .form-submit-print,\n  .form-submit-reset {\n    width: 100%;\n    margin-left: 0!important;\n  }\n  div[id*=at_] {\n    font-size: 14px;\n    font-weight: 700;\n    height: 8px;\n    margin-top: 6px;\n  }\n  .showAutoCalendar {\n    width: 20px;\n  }\n  img.form-image {\n    max-width: 100%;\n    height: auto;\n  }\n  .form-matrix-row-headers {\n    width: 100%;\n    word-break: break-all;\n    min-width: 40px;\n  }\n  .form-collapse-table,\n  .form-header-group {\n    margin: 0;\n  }\n  .form-collapse-table {\n    height: 100%;\n    display: inline-block;\n    width: 100%;\n  }\n  .form-collapse-hidden {\n    display: none !important;\n  }\n  .form-input {\n    width: 100%;\n  }\n  .form-label {\n    width: 100% !important;\n  }\n  .form-label-left,\n  .form-label-right {\n    display: block;\n    float: none;\n    text-align: left;\n    width: auto!important;\n  }\n  .form-line,\n  .form-line.form-line-column {\n    padding: 2% 5%;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  input[type=text],\n  input[type=email],\n  input[type=tel],\n  textarea {\n    width: 100%;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n    max-width: initial !important;\n  }\n  .form-radio-other-input,\n  .form-checkbox-other-input {\n    max-width: 55% !important;\n  }\n  .form-dropdown,\n  .form-textarea,\n  .form-textbox {\n    width: 100%!important;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  .form-input,\n  .form-input-wide,\n  .form-textarea,\n  .form-textbox,\n  .form-dropdown {\n    max-width: initial!important;\n  }\n  .form-checkbox-item:not(#foo),\n  .form-radio-item:not(#foo) {\n    width: 100%;\n  }\n  .form-address-city,\n  .form-address-line,\n  .form-address-postal,\n  .form-address-state,\n  .form-address-table,\n  .form-address-table .form-sub-label-container,\n  .form-address-table select,\n  .form-input {\n    width: 100%;\n  }\n  div.form-header-group {\n    padding: 24px 0px !important;\n    margin: 0 12px 2% !important;\n    margin-left: 5%!important;\n    margin-right: 5%!important;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  div.form-header-group.hasImage img {\n    max-width: 100%;\n  }\n  [data-type=\"control_button\"] {\n    margin-bottom: 0 !important;\n  }\n  [data-type=control_fullname] .form-sub-label-container {\n    width: 48%;\n  }\n  [data-type=control_fullname] .form-sub-label-container:first-child {\n    margin-right: 4%;\n  }\n  [data-type=control_phone] .form-sub-label-container {\n    width: 65%;\n    margin-right: 0;\n    margin-left: 0;\n    float: left;\n  }\n  [data-type=control_phone] .form-sub-label-container:first-child {\n    width: 31%;\n    margin-right: 4%;\n  }\n  [data-type=control_datetime] .allowTime-container {\n    width: 100%;\n  }\n  [data-type=control_datetime] .form-sub-label-container:first-child {\n    width: 10%!important;\n    margin-left: 0;\n    margin-right: 0;\n  }\n  [data-type=control_datetime] .form-sub-label-container + .form-sub-label-container {\n    width: 24%!important;\n    margin-left: 6%;\n    margin-right: 0;\n  }\n  [data-type=control_datetime] span + span + span > span:first-child {\n    display: block;\n    width: 100% !important;\n  }\n  [data-type=control_birthdate] .form-sub-label-container,\n  [data-type=control_time] .form-sub-label-container {\n    width: 27.3%!important;\n    margin-right: 6% !important;\n  }\n  [data-type=control_time] .form-sub-label-container:last-child {\n    width: 33.3%!important;\n    margin-right: 0 !important;\n  }\n  .form-pagebreak-back-container,\n  .form-pagebreak-next-container {\n    min-height: 1px;\n    width: 50% !important;\n  }\n  .form-pagebreak-back,\n  .form-pagebreak-next,\n  .form-product-item.hover-product-item {\n    width: 100%;\n  }\n  .form-pagebreak-back-container {\n    padding: 0;\n    text-align: right;\n  }\n  .form-pagebreak-next-container {\n    padding: 0;\n    text-align: left;\n  }\n  .form-pagebreak {\n    margin: 0 auto;\n  }\n  .form-buttons-wrapper {\n    margin: 0!important;\n    margin-left: 0!important;\n  }\n  .form-buttons-wrapper button {\n    width: 100%;\n  }\n  .form-buttons-wrapper .form-submit-print {\n    margin: 0 !important;\n  }\n  table {\n    width: 100%!important;\n    max-width: initial!important;\n  }\n  table td + td {\n    padding-left: 3%;\n  }\n  .form-checkbox-item,\n  .form-radio-item {\n    white-space: normal!important;\n  }\n  .form-checkbox-item input,\n  .form-radio-item input {\n    width: auto;\n  }\n  .form-collapse-table {\n    margin: 0 5%;\n    display: block;\n    zoom: 1;\n    width: auto;\n  }\n  .form-collapse-table:before,\n  .form-collapse-table:after {\n    display: table;\n    content: '';\n    line-height: 0;\n  }\n  .form-collapse-table:after {\n    clear: both;\n  }\n  .fb-like-box {\n    width: 98% !important;\n  }\n  .form-error-message {\n    clear: both;\n    bottom: -10px;\n  }\n  .date-separate,\n  .phone-separate {\n    display: none;\n  }\n  .custom-field-frame,\n  .direct-embed-widgets,\n  .signature-pad-wrapper {\n    width: 100% !important;\n  }\n}\n\/* | *\/\n\n\/*PREFERENCES STYLE*\/\n    .form-all {\n      font-family: Verdana, sans-serif;\n    }\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-family: Verdana, sans-serif;\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-family: Verdana, sans-serif;\n    }\n    .form-header-group {\n      font-family: Verdana, sans-serif;\n    }\n    .form-label {\n      font-family: Verdana, sans-serif;\n    }\n  \n    \n  \n    .form-line {\n      margin-top: 0px;\n      margin-bottom: 0px;\n    }\n  \n    .form-all {\n      width: 690px;\n    }\n  \n    .form-label.form-label-left,\n    .form-label.form-label-right,\n    .form-label.form-label-left.form-label-auto,\n    .form-label.form-label-right.form-label-auto {\n      width: 150px;\n    }\n  \n    .form-all {\n      font-size: 16px\n    }\n    .form-all .qq-upload-button,\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-size: 16px\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-size: 16px\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: #fff;\n      border: 1px solid transparent;\n    }\n  \n    .form-all {\n      color: #555;\n    }\n    .form-header-group .form-header {\n      color: #555;\n    }\n    .form-header-group .form-subHeader {\n      color: #555;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label {\n      color: #555;\n    }\n    .form-sub-label {\n      color: #6f6f6f;\n    }\n  \n    .supernova {\n      background-color: #f5f5f5;\n    }\n    .supernova body {\n      background: transparent;\n    }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: #fff;\n    }\n  \n    .supernova {\n      background-image: none;\n    }\n    #stage {\n      background-image: none;\n    }\n  \n    .form-all {\n      background-image: none;\n    }\n  \n  .ie-8 .form-all:before { display: none; }\n  .ie-8 {\n    margin-top: auto;\n    margin-top: initial;\n  }\n  \n  \/*PREFERENCES STYLE*\/\/*__INSPECT_SEPERATOR__*\/\r\n\/* CSS Document *\/\r\n@font-face {\r\n    font-family : 'Lato-Regular';\r\n    src : url('Lato-Regular.eot');\r\n    src : url('Lato-Regular.eot?#iefix') format('embedded-opentype'),\r\n           url('Lato-Regular.woff') format('woff'),\r\n           url('Lato-Regular.ttf') format('truetype'),\r\n           url('Lato-Regular.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-Black';\r\n    src : url('\/fonts\/Avenir-Black\/Avenir-Black.eot');\r\n    src : url('\/fonts\/Avenir-Black\/Avenir-Black.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-Black\/Avenir-Black.woff') format('woff'),\r\n           url('\/fonts\/Avenir-Black\/Avenir-Black.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-Black\/Avenir-Black.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-Heavy';\r\n    src : url('\/fonts\/Avenir-Heavy\/Avenir-Heavy.eot');\r\n    src : url('\/fonts\/Avenir-Heavy\/Avenir-Heavy.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-Heavy\/Avenir-Heavy.woff') format('woff'),\r\n           url('\/fonts\/Avenir-Heavy\/Avenir-Heavy.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-Heavy\/Avenir-Heavy.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-Medium';\r\n    src : url('\/fonts\/Avenir-Medium\/Avenir-Medium.eot');\r\n    src : url('\/fonts\/Avenir-Medium\/Avenir-Medium.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-Medium\/Avenir-Medium.woff') format('woff'),\r\n           url('\/fonts\/Avenir-Medium\/Avenir-Medium.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-Medium\/Avenir-Medium.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-Light';\r\n    src : url('\/fonts\/Avenir-Light\/Avenir-Light.eot');\r\n    src : url('\/fonts\/Avenir-Light\/Avenir-Light.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-Light\/Avenir-Light.woff') format('woff'),\r\n           url('\/fonts\/Avenir-Light\/Avenir-Light.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-Light\/Avenir-Light.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-Book';\r\n    src : url('\/fonts\/Avenir-Book\/Avenir-Book.eot');\r\n    src : url('\/fonts\/Avenir-Book\/Avenir-Book.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-Book\/Avenir-Book.woff') format('woff'),\r\n           url('\/fonts\/Avenir-Book\/Avenir-Book.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-Book\/Avenir-Book.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Avenir-MediumOblique';\r\n    src : url('\/fonts\/Avenir-MediumOblique\/Avenir-MediumOblique.eot');\r\n    src : url('\/fonts\/Avenir-MediumOblique\/Avenir-MediumOblique.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Avenir-MediumOblique\/Avenir-MediumOblique.woff') format('woff'),\r\n           url('\/fonts\/Avenir-MediumOblique\/Avenir-MediumOblique.ttf') format('truetype'),\r\n           url('\/fonts\/Avenir-MediumOblique\/Avenir-MediumOblique.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n@font-face {\r\n    font-family : 'Extra-Mile';\r\n    src : url('\/fonts\/Extra-Mile\/Extra-Mile.eot');\r\n    src : url('\/fonts\/Extra-Mile\/Extra-Mile.eot?#iefix') format('embedded-opentype'),\r\n           url('\/fonts\/Extra-Mile\/Extra-Mile.woff') format('woff'),\r\n           url('\/fonts\/Extra-Mile\/Extra-Mile.ttf') format('truetype'),\r\n           url('\/fonts\/Extra-Mile\/Extra-Mile.svg#UbuntuItalic') format('svg');\r\n    font-weight : normal;\r\n    font-style : normal;\r\n}\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label, .form-radio-item:not(#foo) label {\r\n    text-indent : 0px;\r\n    padding-left : 30px;\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label {\r\n    margin-left : 0px;\r\n}\r\n\r\n[data-type=\"control_textbox\"] .form-input, [data-type=\"control_textarea\"] .form-input, [data-type=\"control_fullname\"] .form-input, [data-type=\"control_phone\"] .form-input, [data-type=\"control_datetime\"] .form-input, [data-type=\"control_address\"] .form-input, [data-type=\"control_email\"] .form-input, [data-type=\"control_passwordbox\"] .form-input, [data-type=\"control_autocomp\"] .form-input, [data-type=\"control_textbox\"] .form-input-wide, [data-type=\"control_textarea\"] .form-input-wide, [data-type=\"control_fullname\"] .form-input-wide, [data-type=\"control_phone\"] .form-input-wide, [data-type=\"control_datetime\"] .form-input-wide, [data-type=\"control_address\"] .form-input-wide, [data-type=\"control_email\"] .form-input-wide, [data-type=\"control_passwordbox\"] .form-input-wide, [data-type=\"control_autocomp\"] .form-input-wide {\r\n    width : 100%;\r\n    max-width : 550px;\r\n}\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label, .form-radio-item:not(#foo) label {\r\n    text-indent : 0px;\r\n    padding-left : 30px;\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label {\r\n    margin-left : 0px;\r\n}\r\n\r\n[data-type=\"control_textbox\"] .form-input, [data-type=\"control_textarea\"] .form-input, [data-type=\"control_fullname\"] .form-input, [data-type=\"control_phone\"] .form-input, [data-type=\"control_datetime\"] .form-input, [data-type=\"control_address\"] .form-input, [data-type=\"control_email\"] .form-input, [data-type=\"control_passwordbox\"] .form-input, [data-type=\"control_autocomp\"] .form-input, [data-type=\"control_textbox\"] .form-input-wide, [data-type=\"control_textarea\"] .form-input-wide, [data-type=\"control_fullname\"] .form-input-wide, [data-type=\"control_phone\"] .form-input-wide, [data-type=\"control_datetime\"] .form-input-wide, [data-type=\"control_address\"] .form-input-wide, [data-type=\"control_email\"] .form-input-wide, [data-type=\"control_passwordbox\"] .form-input-wide, [data-type=\"control_autocomp\"] .form-input-wide {\r\n    width : 100%;\r\n    max-width : 550px;\r\n}\r\n\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n.form-multiple-column {\r\n    width : 570px;\r\n}\r\n\r\n#cid_286 div.form-header-group {\r\n    border-top : none;\r\n}\r\n\r\n.form-label.form-label-top {\r\n    width : 700px;\r\n}\r\n\r\n.form-radio-item {\r\n    vertical-align : middle;\r\n}\r\n\r\n#label_input_301_0 {\r\n    width : 550px;\r\n}\r\n\r\n#label_input_263_0, #label_input_263_1, #label_input_263_2 {\r\n    width : 550px;\r\n}\r\n\r\n.form-all {\r\n    font-family : 'Avenir-Book';\r\n}\r\n\r\n.form-header, .form-label {\r\n    font-size : 18px;\r\n    font-family : 'Avenir-Black';\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label, .form-radio-item:not(#foo) label {\r\n    text-indent : 0px;\r\n    padding-left : 30px;\r\n}\r\n\r\nid_255, text_255 p, #text_240 p, text_245 p {\r\n    margin-bottom : 0;\r\n    margin-top : 0;\r\n}\r\n\r\n.form-checkbox-other-input, .form-radio-other-input {\r\n    width : 320px;\r\n}\r\n\r\n#cid_237 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#cid_256 div.form-multiple-column {\r\n    width : 800px;\r\n}\r\n\r\n#text_255 p, text_245 p, text_264 p, text_266 p, text_284 p {\r\n    margin : 0 !important;\r\n}\r\n\r\n#id_264, #id_266 {\r\n    padding-left : 260px;\r\n    padding-top : 0px;\r\n    padding-bottom : 0px;\r\n}\r\n\r\n.form-textbox.form-radio-other-input, .form-textbox.form-checkbox-other-input {\r\n    width : 200px;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) .form-checkbox-other-input, .form-radio-item:not(#foo) .form-radio-other-input {\r\n    margin-top : -10px !important;\r\n}\r\n\r\n#cid_292 span.form-radio-item:last-child, #cid_300 span.form-radio-item:last-child, #cid_269 span.form-checkbox-item:last-child, #cid_254 span.form-radio-item:last-child, #cid_253 span.form-radio-item:last-child, #cid_250 span.form-radio-item:last-child, #cid_251 span.form-radio-item:last-child {\r\n    margin-top : 12px !important;\r\n}\r\n\r\n.form-checkbox-item:not(#foo) label {\r\n    margin-left : 0px;\r\n}\r\n\r\n[data-type=\"control_textbox\"] .form-input, [data-type=\"control_textarea\"] .form-input, [data-type=\"control_fullname\"] .form-input, [data-type=\"control_phone\"] .form-input, [data-type=\"control_datetime\"] .form-input, [data-type=\"control_address\"] .form-input, [data-type=\"control_email\"] .form-input, [data-type=\"control_passwordbox\"] .form-input, [data-type=\"control_autocomp\"] .form-input, [data-type=\"control_textbox\"] .form-input-wide, [data-type=\"control_textarea\"] .form-input-wide, [data-type=\"control_fullname\"] .form-input-wide, [data-type=\"control_phone\"] .form-input-wide, [data-type=\"control_datetime\"] .form-input-wide, [data-type=\"control_address\"] .form-input-wide, [data-type=\"control_email\"] .form-input-wide, [data-type=\"control_passwordbox\"] .form-input-wide, [data-type=\"control_autocomp\"] .form-input-wide {\r\n    width : 100%;\r\n    max-width : 550px;\r\n}\r\n\r\n.form-radio-item:not(#foo) label {\r\n    margin-left : 0px;\r\n}\r\n\r\n[data-type=\"control_fullname\"] .form-sub-label-container {\r\n    width : 30%;\r\n    margin-right : 3%;\r\n}\r\n\r\n[data-type=\"control_birthdate\"] .form-sub-label-container:first-child{\r\n  width: 47%;\r\n}\r\n\r\n#text_311 p{ \r\n  margin-top: 0;\r\n}\r\n\r\nstrong{\r\n  font-family: Avenir-Black;\r\n}\r\n\r\n.cls-rights{\r\n  width: 49%;\r\n  float: left;\r\n  word-break: break-word;\r\n}\r\n\r\n.tbl-first-td {\r\n    padding-right: 1%;\r\n}\r\n\r\n.tbl-nxt-td {\r\n    padding-left: 1%;\r\n}\r\n\r\n#cid_340, #cid_340 .form-checkbox-item{\r\n  max-width: 100%;\r\n}\r\n#label_340{\r\n  display: none;\r\n}\r\n\r\n#label_input_340_0{\r\n  font-weight: bold;\r\n}\r\n\r\n\r\n.form-all{\r\n  width: calc(100% - 20px);\r\n}\r\n.form-label.form-label-left, .form-label.form-label-right, .form-label.form-label-left.form-label-auto, .form-label.form-label-right.form-label-auto{\r\n  width: 210px;\r\n}\r\n.form-input, .form-address-table, .form-matrix-table{\r\n  max-width: 430px;\r\n}\r\n.supernova{\r\n  background-color: transparent;\r\n}\r\n[data-type=\"control_textbox\"] .form-input, [data-type=\"control_textarea\"] .form-input, [data-type=\"control_fullname\"] .form-input, [data-type=\"control_phone\"] .form-input, [data-type=\"control_datetime\"] .form-input, [data-type=\"control_address\"] .form-input, [data-type=\"control_email\"] .form-input, [data-type=\"control_passwordbox\"] .form-input, [data-type=\"control_autocomp\"] .form-input, [data-type=\"control_textbox\"] .form-input-wide, [data-type=\"control_textarea\"] .form-input-wide, [data-type=\"control_fullname\"] .form-input-wide, [data-type=\"control_phone\"] .form-input-wide, [data-type=\"control_datetime\"] .form-input-wide, [data-type=\"control_address\"] .form-input-wide, [data-type=\"control_email\"] .form-input-wide, [data-type=\"control_passwordbox\"] .form-input-wide, [data-type=\"control_autocomp\"] .form-input-wide{\r\n  max-width: 530px;\r\n}\r\n\r\n.form-all .qq-upload-button, .form-all .qq-upload-button, .form-all .form-submit-button, .form-all .form-submit-reset, .form-all .form-submit-print{\r\n  background: #00bfff;\r\n    border-radius: 40px;\r\n    color: #FFFFFF;\r\n    padding: 10px 30px;\r\n    line-height: 26px;\r\n    border: none;  \r\n}\r\n\r\n.qq-upload-button-hover, .form-submit-button-simple_white:hover{\r\n    background: #009bd6  !important;\r\n    color: #FFFFFF !important;\r\n\tborder: none !important;\r\n\toutline: none !important;\r\n      \r\n}\r\n\r\n.qq-uploader{\r\n  width: 250px;\r\n}\r\n.form-line {\r\n    padding: 12px 20px;\r\n}\r\n#cid_269 span.form-checkbox-item:last-child, #cid_292 span.form-radio-item:last-child{\r\n\tmargin-top: 0px !important;\r\n}\r\n\r\n      \r\n.form-sub-label-container {\r\n    width: 100%;\r\n}\n.form-label.form-label-auto {\n        \n        display: inline-block;\n        float: left;\n        text-align: left;\n      \n      }\n    \/* Injected CSS Code *\/\n<\/style>\n\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/buttons\/form-submit-button-simple_white.css?3.3.25229\"\/>\n<script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/punycode\/1.4.1\/punycode.min.js\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/imageinfo.js?v=3.3.25229\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/file-uploader\/fileuploader.js?v=3.3.25229\"><\/script>\n<!--[if lt IE 9]><script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/flashcanvas.js?3.3.25229\" type=\"text\/javascript\"><\/script><![endif]-->\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/jquery-1.8.0.min.js?v=3.3.25229\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/jSignature.min.noconflict.js?3.3.25229\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/jotform.signaturepad.js?3.3.25229\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/prototype.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/jotform.forms.js?3.3.25229\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n\tJotForm.init(function(){\nif (window.JotForm && JotForm.accessible) $('input_239').setAttribute('tabindex',0);\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"360\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":false,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"360\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":false,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\nif (window.JotForm && JotForm.accessible) $('input_242').setAttribute('tabindex',0);\n      setTimeout(function() {\n          $('input_225').hint('ex: myname@example.com');\n       }, 20);\nif (window.JotForm && JotForm.accessible) $('input_302').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_303').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_304').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_258').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_259').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_278').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_305').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_306').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_307').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_287').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_288').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_289').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_290').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_295').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_296').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_297').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_344').setAttribute('tabindex',0);\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"346\", false, 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We are happy you have chosen us for your care. To register, please complete this&nbsp;form. Several of the items below help us ensure that we are meeting the needs of the population we serve, so please be&nbsp;as thorough as you can. Let us know if you have any questions or if you need help in completing this form.\",\"type\":\"control_text\"},null,{\"name\":\"clickTo313\",\"qid\":\"313\",\"text\":\"Welcome to Whitman-Walker Health! We look forward to you joining our healthcare family. Incorporated in 1978,\u00a0Whitman-Walker Health is a nonprofit community health center focused on removing barriers\u00a0to accessing care in the Washington, DC, metropolitan area. Whitman-Walker works to provide stigma-free\u00a0healthcare and support services to the gay, lesbian, bisexual, transgender and non-binary communities of greater\u00a0Washington, and people living with or affected by HIV. Through multiple locations in the district, Whitman-Walker\u00a0serves 20,000 individuals with medical and dental care, mental health and addiction services, legal services, youth\u00a0programming and more. We extend affirmation, dignity and respect to everyone we provide care to.\\nThis packet includes the following:\\n\\nPatient Registration\\nConsents and Acknowledgement\\nPatient Acknowledgement of Financial Obligation\\nPatient Rights and Responsibilities Statement\\nNotice of Privacy Practices\\n\\nYou might be wondering why it\u2019s important for you to completely fill out your registration form.\u00a0Here\u2019s why:\\n\\nThe information you provide helps us learn about you and better serve you. This information includes\u00a0your preferred name and gender pronouns.\\nIt also helps us comply with grants we apply for and provide services through. To keep receiving grant\u00a0funding and serve you affordable care, we need for you to answer all questions on the form, including\u00a0information about your annual income, family size, and housing.\\n\\nThis information will become a part of your health record. It is kept confidential. It is protected by\u00a0law just like all of your health information.\\nThank you for choosing Whitman-Walker Health for your healthcare needs and for taking time to complete these\u00a0forms. We appreciate you!\\nSincerely,\\nSarah Henn, MDChief Health Officer\\n\u00a0\",\"type\":\"control_text\"},null,{\"name\":\"acknowledgementOf\",\"qid\":\"315\",\"text\":\"Acknowledgement of Responsibility for Payment for Services and Assignment of Benefits\",\"type\":\"control_head\"},{\"name\":\"clickTo316\",\"qid\":\"316\",\"text\":\"\\nI understand that I am responsible for all charges and fees for my care, except any that might be covered by insurance accepted by WWH.\\nI understand that payment, including co-insurance, co-pays and self pay \\u002F sliding fee payments, is due at the time of service.\\nFor uninsured or underinsured clients: I understand that if my income, family size, or residency changes, I will bring in documentation of those changes to&nbsp;the Public Benefits and Insurance Navigators. Navigators will re-assess my eligibility for insurance on the sliding fee scale and\\u002For grant-supported care.\\n\",\"type\":\"control_text\"},{\"name\":\"clickTo317\",\"qid\":\"317\",\"text\":\"Consents and Acknowledgements\",\"type\":\"control_text\"},{\"name\":\"divider318\",\"qid\":\"318\",\"type\":\"control_divider\"},{\"name\":\"divider319\",\"qid\":\"319\",\"type\":\"control_divider\"},{\"name\":\"clickTo320\",\"qid\":\"320\",\"text\":\"In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we\u00a0have provided you with certain important information and documents. If you have any questions about any of this information or\u00a0need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable\u00a0with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask\u00a0questions, and are giving your consent.\\n\u00a0\\nGENERAL CONSENT TO TREAT\\nI voluntarily agree to receive services from WWH, and authorize the providers of WWH to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. Finally, I know that WWH sometimes has students\\u002Fresidents being trained as doctors, nurses, therapists and other health care providers who might be helping to care for me. These individuals are under the supervision of licensed providers. I understand that WWH is committed to involving me in my care and that no one can be given care at WWH without agreeing to the care unless there is an emergency. If there is an emergency, I know that someone at WWH may help me without waiting for me to say okay. I understand that some services require me to sign another Informed Consent to Treatment so I may be asked to complete that later.\\n\u00a0\\nNOTICE OF PRIVACY PRACTICE\\nI have been given a copy of WWH\u2019s Notice of Privacy Practices and I understand that WWH is required by law to protect my personal health information. I have had the chance to ask questions about WWH\u2019s Notice of Privacy Practices and feel comfortable with the protections that it offers me. I understand that there are times when the law allows my personal health information to be shared with individuals or entities outside of WWH, including but not limited to for treatment, payment and operations purposes, when required by law, and in connection with the mandatory reporting of certain diseases.\\n\u00a0\\nINTEGRATED MODEL OF CARE\\nWWH offers a wide variety of services to its clients. I understand that in order for me to get the best service for my needs, programs within WWH may share information concerning my health to ensure the quality and continuity of my care across service areas. For example, WWH may share my demographic information, medical and other service referrals, and other non-clinical information with WWH Legal Services to allow for legal referrals and for scheduling purposes. The details of my health records will only be shared with WWH lawyers if I agree for them to take my legal case.\\n\u00a0\\nHEALTH INFORMATION EXCHANGE AND PDMP\\nI understand that WWH participates in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange (HIE) and the Capital Partners in Care (CPC) HIE. These HIEs provide a way of sharing my health information among participating doctors\u2019 offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. I have been informed that my health information, including information relating to the mental health services I receive at WWH, will be shared with the HIEs in order to better coordinate my care and assist providers and public health officials in making more informed decisions. I have been advised by WWH that I have the right to \u201copt-out\u201d of the HIEs at any time. I understand that I can request a copy of WWH\u2019s \u201copt-out\u201d form and direct WWH to disable access to my health information, except to the extent that disclosure of such information is permitted or mandated by law. \\nI also acknowledge that it may be necessary for my Whitman-Walker Health provider to obtain information about my medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.\\n\u00a0\\nPatient Rights and Responsibilities\\nI have been given a copy of the WWH Rights and Responsibilities document and understand that both WWH and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint or grievance with WWH, as described on the WWH website and in the Patient Feedback notice posted on bulletin boards at the health center. I also understand that WWH has a Patient Handbook that contains information about being a patient at WWH including services offered, hours of operation and contact information.\\n\u00a0\\nRELEASE OF INFORMATION FOR BILLING AND CONSENT TO REIMBURSE\\nI know that WWH needs to send parts of my personal health information to organizations that help pay for my care, such as my insurance company or an organization that grants money to WWH. I allow WWH to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act (HIPAA).\\n\u00a0\\nCONSENT TO COMMUNICATIONS VIA E-COMMUNICATIONS\\nThe U. S. Department of Health and Human Services permits patients to request electronic communications with their providers. I acknowledge that the most secure means of communicating with WWH is by use of the patient portal. Any other method of communicating electronically presents a greater risk of breach of privacy because the communications may be intercepted by third parties or transmitted to unintended parties. WWH will make an effort to limit the information it includes in e-communications with me. I understand, however, that information about my medical care (including appointments, billing information, prescriptions and test results) may be sent to me electronically. By signing below, I am choosing and consenting freely to electronic communications. If I wish to discontinue e-communications with WWH, I can submit an E-communications Opt-Out Form available from Client Services or on the WWH website.\\n\u00a0\\nACKNOWLEDGMENT OF DUTY TO REIMBURSE WWH FOR HEALTH CARE SERVICES\\nI understand that WWH offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay based on their level of income. In order to be eligible for WWH\u2019s Sliding Fee Scale of discounted or free services, I will need to provide WWH\u2019s Public Benefits and Insurance Navigation team with documents establishing that I meet income eligibility requirements. If I do not provide the required documents to WWH, I am responsible for paying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service. I also understand that if I am an insured patient with insurance WWH does not accept, or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid.\\n\u00a0\\nBy signing my name below, I am acknowledging that I have read, and fully understand, each of the separate paragraphs set forth above.\",\"type\":\"control_text\"},null,null,{\"name\":\"clickTo323\",\"qid\":\"323\",\"text\":\"Patient Acknowledgement of Financial Obligation\",\"type\":\"control_text\"},null,{\"name\":\"clickTo325\",\"qid\":\"325\",\"text\":\"PREAMBLE\\nWhitman-Walker Health (&ldquo;WWH&rdquo;) is a Federally Qualified Health Center (&ldquo;FQHC&rdquo; or &ldquo;Health Center&rdquo;) that is subject to Section 330 of the Public Health Service Act. Section 330 specifies that Health Centers must assure that no patient will be denied services due to their inability to pay for such services. It also requires Health Centers to adopt written policies and procedures to maximize collections and reimbursement for their costs in providing health services.\\n&nbsp;&nbsp;\\nI UNDERSTAND THAT I AM RESPONSIBLE FOR:\\n\\nContributing to the cost of my care and treatment as my health insurance coverage requires and based on my ability to pay;\\nProviding WWH with the information it needs to receive reimbursement for the treatment or services it provides to me;\\nRequesting consideration for discounted fees under WWH&rsquo;s Sliding Fee Scale based on my level of income, and providing documentation to support eligibility for discounted fees that may be requested by WWH&rsquo;s Public Benefits and Insurance Navigation team;\\nAssisting the Public Benefits and Insurance Navigators with any application for insurance or public benefits that I may be entitled to;\\nPaying my co-payment (if applicable) when I check-in for my appointment and paying my deductible or any other fees that may be owed at the conclusion of the medical visit;\\nPaying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service, either upon check-in or at check-out as requested by WWH if I have been deemed a self-pay patient based on the fact that I have insurance coverage that WWH does not accept but have elected to remain in care at WWH.\\n\\nI understand that if I am an insured self-pay patient or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid. If I fail to pay my outstanding fees or copays in 30 days, WWH presumes that you are transitioning your care to another provider. If you have a health care issue requiring immediate care during the next 30 days, you may contact WWH and your provider will determine whether you should be seen. To prevent you from running out of medications, a thirty (30) day renewal will be made available if needed.\",\"type\":\"control_text\"},null,{\"name\":\"submit\",\"qid\":\"327\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"name\":\"clickTo328\",\"qid\":\"328\",\"text\":\"\\nAS A WWH PATIENT, YOU HAVE THE RIGHT TO:\\nACCESS SERVICES in a safe and respectful manner\\n\\nReceive services at WWH regardless of your race, color, religion, sex, marital status, sexual orientation, gender identity or expression, English language proficiency, national origin, age, disability, veteran status, or any other status protected by law.\\n\\n\\n\\nReceive respect and consideration from every employee, volunteer or trainee you interact with at WWH.\\n\\n\\nFeel safe from harm and free from verbal, physical, or psychological abuse, intimidation or harassment when you are at WWH\u2019s facilities.\\n\\n\\nPRIVACY regarding your personal health information\\n\\n\\nExpect WWH to comply with the Federal and State privacy laws when using or disclosing information about you or the health care and related services you receive at WWH.\\n\\n\\nReceive a copy of WWH\u2019s Notice of Privacy Practices when you register as a new patient so that you will be more fully informed about your privacy rights.\\n\\n\\nActive involvement in your ongoing care\\n\\n\\nHelp WWH providers and staff to develop a plan for the treatment and services you receive at WWH.\\n\\n\\nProvide (or withhold) your consent to voluntary treatment, including your participation in clinical research, and be informed about the consequences of refusing any treatment or service.\\n\\n\\nProvide WWH staff members with positive or negative feedback about your care, or voice your concerns or complaints about the Health Center.\\n\\n\\nTIMELY INFORMATION about your care\\n\\n\\nReceive complete information about your diagnosis, and treatment or service plan in plain language that you can understand.\\n\\n\\nObtain a copy of your medical records upon request unless the law permits WWH to withhold the records.\\n\\n\\nReceive an explanation of the costs associated with your care at WWH.\\n\\n\\nObtain assistance with referrals to other providers.\\n\\n\\nQUALITY SERVICES from our health center\\n\\n\\nReceive coordinated health care treatment and services consistent with professional standards.\\n\\n\\nReceive services from licensed and credentialed WWH providers.\\n\\n\\nRequest WWH to provide hearing, language, literacy or other communication assistance required by law.\\n\\n\\nReceive services and care in the least restrictive environment feasible, free from chemical or physical restraints.\\n\\n\\n\\n\\nAS A WWH PATIENT, YOU ARE RESPONSIBLE FOR:\\nYOUR PERSONAL INTERACTIONS with our health center team\\n\\nTreat WWH employees, volunteers, trainees, contractors, other patients, and guests with respect at all times.\\nDo not make any threatening or offensive statements at WWH\u2019s facilities.\\nDo not engage in any act of physical violence or other threatening or inappropriate behavior at WWH\u2019s facilities, which includes bringing a weapon of any kind on site.\\nDo not distribute or use alcohol or drugs on WWH\u2019s property or enter a WWH facility or program under the influence of illegal drugs or alcohol.\\n\\nACTIVE ENGAGEMENT in your care\\n\\nTake an active part in your treatment or service plan at WWH and stay in contact with your providers about your care.\\nRequest any hearing, language, literacy or other communications assistance you may need at least 48 hours prior to your visit.\\nShow up for your appointments at least 15 minutes ahead of schedule and provide advance notice whenever it becomes necessary to cancel an appointment at WWH.\\nContribute to the cost of your care that the law or the health plan that you participate in require you to pay.\\n\\nTIMELY INFORMATION sharing\\n\\n\\nProvide WWH with complete, accurate, and truthful information at all times.\\nWWH\u2019s Patient Rights and Responsibilities Policy grants WWH discretion to take action placing limits on a patient\u2019s ability to receive treatment or services at WWH based on a patient\u2019s failure to meet their Responsibilities or for any other reason permitted by law. Likewise, any WWH patient has discretion to decide not to seek further treatment or services at WWH based on WWH\u2019s failure to abide by the patient Rights set forth in this Statement or for any other reason.\\n\\n\\n\",\"type\":\"control_text\"},{\"name\":\"clickTo329\",\"qid\":\"329\",\"text\":\"Patient Rights and Responsibilities Statement\",\"type\":\"control_text\"},null,{\"name\":\"divider331\",\"qid\":\"331\",\"type\":\"control_divider\"},null,{\"name\":\"clickTo333\",\"qid\":\"333\",\"text\":\"Notice of Privacy Practices\",\"type\":\"control_text\"},{\"name\":\"clickTo334\",\"qid\":\"334\",\"text\":\"\\nThis Notice describes how medical information about you may&nbsp;be used and disclosed by Whitman-Walker Health (WWH) and&nbsp;how you can get access to this information. Please review it&nbsp;carefully.\\nYOUR RIGHTS\\nYou have the right to:\\n\\nGet a copy of your paper or electronic medical record\\nCorrect your paper or electronic medical record\\nRequest confidential communications\\nAsk us to limit the information about you that we share\\nGet a list of those with whom we&rsquo;ve shared your information\\nGet a copy of this Notice of Privacy Practices\\nChoose someone to act as your personal representative for purposes of your health information\\nFile a complaint if you believe your privacy rights have been violated\\n\\nYOUR CHOICES\\nYou have some choices in the way that we use and share information as we:\\n\\nTell family and friends about your health\\nProvide disaster relief\\nProvide mental health care\\nMarket our services and sell your information\\nRaise funds\\n\\nOUR USES AND DISCLOSURES\\nWe may use and share your information as we:\\n\\nTreat you\\nRun our organization\\nBill for your services\\nHelp with public health and safety issues\\nDo research\\nComply with the law\\nRespond to organ and tissue donation requests\\nWork with a medical examiner or funeral director\\nAddress workers&rsquo; compensation, law enforcement, and other government requests\\nRespond to lawsuits and legal actions\\n\\nA more detailed description of your rights, your choices and our uses and disclosures of your health information is set forth below:\\n&nbsp;\\nYOUR RIGHTS\\nWhen it comes to your health information, you have certain rights. This section of our Notice of Privacy Practices explains your rights and some of our responsibilities under the law.\\nGet an electronic or paper copy of your medical record.\\n\\nYou can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.\\nWe will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.\\nYou can ask us to correct health information about you that you think is incorrect or incomplete.\\n\\nAsk us to amend your medical record\\nWe may say &ldquo;no,&rdquo; but we&rsquo;ll tell you why in writing within 60 days In these cases we generally do not share your information unless you give us written permission:\\n\\nMarketing purposes\\nSale of your information\\nMost sharing of psychotherapy notes\\n\\nIn the case of fundraising:\\n\\nWe may contact you for fundraising efforts, but you can tell us not to contact you again.\\n\\nOUR USES AND DISCLOSURES OF INFORMATION ABOUT YOU\\nHow do we typically use or share your health information?\\nWe typically use or share your health information in the following ways.\\nTo treat you\\nWe can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.\\nTo run our organization\\nWe can use and share your health information to run our health center, improve your care, and contact you when necessary. Example: We use health information about you to improve the quality of care we provide to you and others.\\nIn order to bill for your services\\nWe can use and share your health information to bill and get payment from health plans or other entities. Example: We can give information about you to your health\\ninsurance plan in order to be paid for the services you receive at the health center.\\nHOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?\\nWe are allowed or required to share your information in other ways&mdash;usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. If you want to learn more you can go to: www.hhs.gov\\u002Focr\\u002Fprivacy\\u002Fhipaa\\u002Funderstanding\\u002Fconsumers\\u002Findex.html\\nHelp with public health and safety issues\\nWe can share health information about you for certain situations such as:\\n\\nPreventing disease\\nHelping with product recalls\\nReporting adverse reactions to medications\\nReporting suspected abuse, neglect, or domestic violence\\nPreventing or reducing a serious threat to anyone&rsquo;s health or safety\\n\\n&nbsp;\\nRequest confidential communications\\nMake a reasonable request to contact you in a specific way (for example, home or office phone) or to send mail to a different address.Ask us to limit what we use or share\\nYou can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say &ldquo;no&rdquo; if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say &ldquo;yes&rdquo; unless a law requires us to share that information.&nbsp;\\n\\n\\nDo research\\nWe can use or share your information for health research.\\nComply with the law\\nWe will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we&rsquo;re complying with federal privacy la\\nGet a list of those with whom we&rsquo;ve shared information\\n\\nYou can ask for a list (accounting) of the times we&rsquo;ve shared your health information for six years prior to the date you ask, who we shared it with, and why.\\nWe will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We&rsquo;ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.\\n\\nGet a copy of this Notice of Privacy Practices\\n\\nYou can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically and we will provide you with a paper copy promptly.\\n\\nChoose someone to act for you\\n\\nIf you have given someone health care power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.\\nOur Legal Services Department can assist you with the preparation of a health care power of attorney document that provides authority for another person to act on your behalf.\\n\\nFile a complaint if you feel your rights are violated\\n\\nYou can complain if you feel we have violated your rights by contacting Whitman-Walker&rsquo;s Privacy Officer at 202.939.7694.\\nYou can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington, DC 20201, calling 1.877. 696.6775, or visiting www.hhs.gov\\u002Focr\\u002Fprivacy\\u002Fhipaa\\u002Fcomplaints.\\nWe will not retaliate against you for filing a complaint.\\n\\nYOUR CHOICES\\nFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:\\n\\nShare information with your family, close friends, or others involved in your care\\nShare information in a disaster relief situation\\n\\nIf you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.\\nRespond to organ and tissue donation requests\\nWe can share health information about you with organ procurement organizations.\\nWork with a medical examiner or funeral director\\nWe can share health information about a deceased patient with a coroner, medical examiner, or funeral director.\\nAddress workers&rsquo; compensation, law enforcement, and other&nbsp;government requests.\\nWe can use or share health information about you:\\n\\nFor workers&rsquo; compensation claims\\nFor law enforcement purposes or with a law enforcement official\\nWith health oversight agencies for activities authorized by law\\nFor special government functions such as military, national security, and presidential protective services\\n\\nRespond to lawsuits and legal actions\\nWe can share health information about you in response to a court or administrative order, or in response to a subpoena.\\nOUR RESPONSIBILITIES\\n\\nWe are required by law to maintain the privacy and security of your protected health information.\\nWe will let you know in writing if a breach occurs that may have compromised the privacy or security of your information.\\nWe must follow the duties and privacy practices described in this Notice and give you a copy of it.\\nWe will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.\\nWe do not share records relating to your participation in a WWH substance abuse program or your mental health records with providers outside of WWH without your written authorization.\\n\\nThe original effective date of this Notice is April 14, 2003 and the Notice was most recently updated on September 24, 2019. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice of Privacy Practices will be available upon request, in our office, and on our web site.\\nWWH is participating in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange and the Capital Partners in Care (CPC) Health Information Exchange. These health information exchanges (HIEs) provide a way of sharing your health information among participating doctors&rsquo; offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. As permitted by DC Mental Health Information Amendment Act of 2018, your mental health information will be shared with the CPC and CRISP HIEs to provide faster access, better coordination of care, and improved knowledge for providers. If you do not want your mental health information to be shared among your providers, you have the right to opt-out of the HIEs at any time by completing an Opt-Out Form available at the Front Desk. Note, however, that it is not possible to share some but not all of your health and mental health information. If you opt-out of one or both HIEs, none of your health information will be shared with that HIE for purposes of coordinating your care and treatment. It may also necessary for your Whitman-Walker Health provider to obtain information about your medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.\\nAcknowledgement of receipt of this Notice of Privacy Practices is indicated by your signature on our Informed Consent Form that is scanned into your electronic medical record.\\n\",\"type\":\"control_text\"},null,null,{\"name\":\"divider337\",\"qid\":\"337\",\"type\":\"control_divider\"},{\"name\":\"divider338\",\"qid\":\"338\",\"type\":\"control_divider\"},{\"name\":\"input339\",\"qid\":\"339\",\"text\":\"Telehealth\\n\u00a0\\nCONSENT TO RECEIVE MEDICAL, DENTAL AND BEHAVIORAL HEALTH SERVICES VIA TELEHEALTH\\nThis form gives you facts about, and risks of, telehealth services.\\nBy signing this form, or verbally agreeing to its terms, you consent to receive telehealth services and treatment by a Whitman-Walker Health medical, dental or behavioral health provider, and you acknowledge your understanding and agreement to the following:\\n\\nYou will be participating in a medical, dental or behavioral health telehealth visit at a location different from where your Whitman-Walker Health provider is located, which may limit the ability of your provider to provide medical care. For example, your provider will not be able to conduct an in-person physical examination and cannot provide emergency medical services during a telehealth visit.\\nIt is the role of your provider to determine whether or not the condition you are being diagnosed with or treated for is appropriate for a telehealth visit.\\nYou or your provider may require an in-person examination before or after diagnosing or prescribing a treatment plan.\\nIf you are experiencing a medical or mental health emergency, you understand you will be asked to immediately call 911 or go to the nearest emergency room.\\nThis telehealth visit and future telehealth visits will be conducted with the use of real-time interactive two-way audio, video or other electronic communications. Whitman-Walker Health has taken steps to protect the security of information disclosed during the session, but Internet security and privacy are not guaranteed. You understand that (1) security protocols could fail, potentially causing a breach of your protected health information, (2) information you transmit through telehealth technology may be insufficient to allow for appropriate medical decision-making by your provider (for example, poor image resolution); or (3) failures of equipment (for example, servers, devices) or infrastructure (for example, communications lines, power supply) may cause delays in medical evaluation and treatment, or loss of information, and you agree to hold Whitman-Walker Health harmless for any loss of protected health information that occurs due to technological failure.\\nWhitman-Walker Health will need to obtain an accurate medical and mental health history, condition(s) and description of current or previous medical or mental health care from you during telehealth sessions to best support diagnosis, therapy, follow-up and\\u002For education.\\nYour provider may have other medical staff participate in your telehealth visit and you agree to medical staff participation. You have the right, at any time, to request the medical staff to leave the telehealth visit.\\nIf you allow another person to participate in your telehealth visit (e.g., family, caregiver), you consent to their participation.\\nWhitman-Walker Health may share your identifiable information from your telehealth visits with third parties, except as prohibited by law. Whitman-Walker Health may separately request your consent to share identifiable information from your telehealth visits with third parties, as necessary.\\nThere are potential risks to telehealth, such as technological interruptions, unauthorized access, and technical difficulties. Your provider will obtain or confirm your contact information in order to reach you in the event of a technical issue.\\nYou or your provider can stop any telehealth visit if either of you feel that the videoconferencing connections are not adequate for the situation.\\nHaving a telehealth visit is your choice. Even if you have agreed to the session, you can change your mind about participating in this or future telehealth sessions. You have the right to withdraw your consent.\\n\\nBY SIGNING YOUR NAME BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ (OR HAVE HAD READ TO YOU), AND UNDERSTAND EACH OF THE SEPARATE PARAGRAPHS ABOVE, YOU HAVE HAD A CHANCE TO ASK WHITMAN-WALKER HEALTH STAFF ANY QUESTIONS YOU MAY HAVE, AND YOU CONSENT TO THE TELEHEALTH SERVICES AND TREATMENT PROVIDED TO YOU BY WHITMAN-WALKER HEALTH.\\nThis Consent lasts for as long as telehealth services continue, unless you exercise your right to withdraw your consent at any time.\\nIf you are not able to place a wet signature or electronic signature on this Consent and return it to Whitman-Walker Health, you will verbally inform Whitman-Walker Health that you have reviewed this form and provide your verbal consent. 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We will need your identification and an email to set up a patient portal account.\",\"type\":\"control_text\"},null,null,null,null,{\"description\":\"\",\"name\":\"genderIdentity\",\"qid\":\"250\",\"text\":\"Gender Identity\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"sexAt\",\"qid\":\"251\",\"text\":\"Sex at Birth\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"doYou252\",\"qid\":\"252\",\"text\":\"Do you identify as transgender?\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"sexualOrientation\",\"qid\":\"253\",\"text\":\"Sexual Orientation\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"genderPronouns\",\"qid\":\"254\",\"text\":\"Gender Pronouns\",\"type\":\"control_radio\"},{\"name\":\"clickTo255\",\"qid\":\"255\",\"text\":\"Wellness services available for existing eligible patients:\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"input256\",\"qid\":\"256\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"name\":\"divider257\",\"qid\":\"257\",\"type\":\"control_divider\"},{\"description\":\"\",\"name\":\"annualFamily258\",\"qid\":\"258\",\"subLabel\":\"\",\"text\":\"Annual Family Income\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"familySize\",\"qid\":\"259\",\"subLabel\":\"\",\"text\":\"Family Size\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"ethnicity\",\"qid\":\"260\",\"text\":\"Ethnicity\",\"type\":\"control_checkbox\"},null,{\"description\":\"\",\"name\":\"input262\",\"qid\":\"262\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"race\",\"qid\":\"263\",\"text\":\"Race\",\"type\":\"control_checkbox\"},{\"name\":\"clickTo264\",\"qid\":\"264\",\"text\":\"Asian (please specify)\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"typeA\",\"qid\":\"265\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"name\":\"clickTo266\",\"qid\":\"266\",\"text\":\"Native Hawaiian\\u002FPacific Islander (please specify)\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"typeA267\",\"qid\":\"267\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"name\":\"divider268\",\"qid\":\"268\",\"type\":\"control_divider\"},{\"description\":\"\",\"name\":\"language\",\"qid\":\"269\",\"text\":\"Language\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"input270\",\"qid\":\"270\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"deafOr\",\"qid\":\"271\",\"text\":\"Deaf or hard of hearing\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"preference\",\"qid\":\"272\",\"text\":\"Preference\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"doYou273\",\"qid\":\"273\",\"text\":\"Do you have an advanced health care directive?\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"ifNo\",\"qid\":\"274\",\"text\":\"If no, would you like more information?\",\"type\":\"control_radio\"},{\"name\":\"emergencyContact\",\"qid\":\"275\",\"text\":\"Emergency Contact Information\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"name276\",\"qid\":\"276\",\"text\":\"Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"277\",\"text\":\"Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"relationship\",\"qid\":\"278\",\"subLabel\":\"\",\"text\":\"Relationship\",\"type\":\"control_textbox\"},null,null,null,{\"name\":\"paymentAnd\",\"qid\":\"282\",\"text\":\"Payment and Insurance Information\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"areYou\",\"qid\":\"283\",\"text\":\"Are you insured?\",\"type\":\"control_radio\"},{\"name\":\"clickTo284\",\"qid\":\"284\",\"text\":\"If you do not have insurance, you must meet with the Public Benefits and Insurance Navigators. You may be eligible for insurance or our sliding fee schedule for your services. In order to determine your eligibility, you must provide income, family size, and residency documentation. Until we receive your documentation, you will be responsible for the full fee for your services.\",\"type\":\"control_text\"},{\"name\":\"insurancesWe\",\"qid\":\"285\",\"text\":\"Insurances we do not accept\",\"type\":\"control_head\"},{\"name\":\"insuranceInformation\",\"qid\":\"286\",\"text\":\"Insurance Information\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"company\",\"qid\":\"287\",\"subLabel\":\"\",\"text\":\"Company\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"identificationNumber\",\"qid\":\"288\",\"subLabel\":\"\",\"text\":\"Identification Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"groupNumber\",\"qid\":\"289\",\"subLabel\":\"\",\"text\":\"Group Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"contactNumber290\",\"qid\":\"290\",\"subLabel\":\"(on back of card)\",\"text\":\"Contact Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"inWhose\",\"qid\":\"291\",\"text\":\"In whose name is your insurance?\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"ifPrivatecommercial\",\"qid\":\"292\",\"text\":\"If private\\u002Fcommercial insurance\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"isThe\",\"qid\":\"293\",\"text\":\"Is the responsible party a Whitman-Walker patient?\",\"type\":\"control_radio\"},{\"name\":\"secondaryInsurance\",\"qid\":\"294\",\"text\":\"Secondary Insurance Information\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"company295\",\"qid\":\"295\",\"subLabel\":\"\",\"text\":\"Company\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"identificationNumber296\",\"qid\":\"296\",\"subLabel\":\"\",\"text\":\"Identification Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"contactNumber\",\"qid\":\"297\",\"subLabel\":\"(on back of card)\",\"text\":\"Contact Number\",\"type\":\"control_textbox\"},{\"name\":\"sexgenderMarker\",\"qid\":\"298\",\"text\":\"Sex\\u002FGender Marker with Insurance Company\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"wwhRecognizes\",\"qid\":\"299\",\"text\":\"WWH recognizes your gender identity. For insurance billing purposes, what sex\\u002Fgender marker is on file with your insurance company?\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"isYour300\",\"qid\":\"300\",\"text\":\"Is your legal name on your insurance card?\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"input301\",\"qid\":\"301\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"cellNumber\",\"qid\":\"302\",\"subLabel\":\"\",\"text\":\"Cell Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"homeNumber\",\"qid\":\"303\",\"subLabel\":\"\",\"text\":\"Home Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"workNumber\",\"qid\":\"304\",\"subLabel\":\"\",\"text\":\"Work Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"cellNumber305\",\"qid\":\"305\",\"subLabel\":\"\",\"text\":\"Cell Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"workNumber306\",\"qid\":\"306\",\"subLabel\":\"\",\"text\":\"Work Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"homeNumber307\",\"qid\":\"307\",\"subLabel\":\"\",\"text\":\"Home Number\",\"type\":\"control_textbox\"},null,null,null,{\"name\":\"clickTo311\",\"qid\":\"311\",\"text\":\"Welcome to Whitman-Walker Health! We are happy you have chosen us for your care. To register, please complete this&nbsp;form. Several of the items below help us ensure that we are meeting the needs of the population we serve, so please be&nbsp;as thorough as you can. Let us know if you have any questions or if you need help in completing this form.\",\"type\":\"control_text\"},null,{\"name\":\"clickTo313\",\"qid\":\"313\",\"text\":\"Welcome to Whitman-Walker Health! We look forward to you joining our healthcare family. Incorporated in 1978,\u00a0Whitman-Walker Health is a nonprofit community health center focused on removing barriers\u00a0to accessing care in the Washington, DC, metropolitan area. Whitman-Walker works to provide stigma-free\u00a0healthcare and support services to the gay, lesbian, bisexual, transgender and non-binary communities of greater\u00a0Washington, and people living with or affected by HIV. Through multiple locations in the district, Whitman-Walker\u00a0serves 20,000 individuals with medical and dental care, mental health and addiction services, legal services, youth\u00a0programming and more. We extend affirmation, dignity and respect to everyone we provide care to.\\nThis packet includes the following:\\n\\nPatient Registration\\nConsents and Acknowledgement\\nPatient Acknowledgement of Financial Obligation\\nPatient Rights and Responsibilities Statement\\nNotice of Privacy Practices\\n\\nYou might be wondering why it\u2019s important for you to completely fill out your registration form.\u00a0Here\u2019s why:\\n\\nThe information you provide helps us learn about you and better serve you. This information includes\u00a0your preferred name and gender pronouns.\\nIt also helps us comply with grants we apply for and provide services through. To keep receiving grant\u00a0funding and serve you affordable care, we need for you to answer all questions on the form, including\u00a0information about your annual income, family size, and housing.\\n\\nThis information will become a part of your health record. It is kept confidential. It is protected by\u00a0law just like all of your health information.\\nThank you for choosing Whitman-Walker Health for your healthcare needs and for taking time to complete these\u00a0forms. We appreciate you!\\nSincerely,\\nSarah Henn, MDChief Health Officer\\n\u00a0\",\"type\":\"control_text\"},null,{\"name\":\"acknowledgementOf\",\"qid\":\"315\",\"text\":\"Acknowledgement of Responsibility for Payment for Services and Assignment of Benefits\",\"type\":\"control_head\"},{\"name\":\"clickTo316\",\"qid\":\"316\",\"text\":\"\\nI understand that I am responsible for all charges and fees for my care, except any that might be covered by insurance accepted by WWH.\\nI understand that payment, including co-insurance, co-pays and self pay \\u002F sliding fee payments, is due at the time of service.\\nFor uninsured or underinsured clients: I understand that if my income, family size, or residency changes, I will bring in documentation of those changes to&nbsp;the Public Benefits and Insurance Navigators. Navigators will re-assess my eligibility for insurance on the sliding fee scale and\\u002For grant-supported care.\\n\",\"type\":\"control_text\"},{\"name\":\"clickTo317\",\"qid\":\"317\",\"text\":\"Consents and Acknowledgements\",\"type\":\"control_text\"},{\"name\":\"divider318\",\"qid\":\"318\",\"type\":\"control_divider\"},{\"name\":\"divider319\",\"qid\":\"319\",\"type\":\"control_divider\"},{\"name\":\"clickTo320\",\"qid\":\"320\",\"text\":\"In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we\u00a0have provided you with certain important information and documents. If you have any questions about any of this information or\u00a0need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable\u00a0with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask\u00a0questions, and are giving your consent.\\n\u00a0\\nGENERAL CONSENT TO TREAT\\nI voluntarily agree to receive services from WWH, and authorize the providers of WWH to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. Finally, I know that WWH sometimes has students\\u002Fresidents being trained as doctors, nurses, therapists and other health care providers who might be helping to care for me. These individuals are under the supervision of licensed providers. I understand that WWH is committed to involving me in my care and that no one can be given care at WWH without agreeing to the care unless there is an emergency. If there is an emergency, I know that someone at WWH may help me without waiting for me to say okay. I understand that some services require me to sign another Informed Consent to Treatment so I may be asked to complete that later.\\n\u00a0\\nNOTICE OF PRIVACY PRACTICE\\nI have been given a copy of WWH\u2019s Notice of Privacy Practices and I understand that WWH is required by law to protect my personal health information. I have had the chance to ask questions about WWH\u2019s Notice of Privacy Practices and feel comfortable with the protections that it offers me. I understand that there are times when the law allows my personal health information to be shared with individuals or entities outside of WWH, including but not limited to for treatment, payment and operations purposes, when required by law, and in connection with the mandatory reporting of certain diseases.\\n\u00a0\\nINTEGRATED MODEL OF CARE\\nWWH offers a wide variety of services to its clients. I understand that in order for me to get the best service for my needs, programs within WWH may share information concerning my health to ensure the quality and continuity of my care across service areas. For example, WWH may share my demographic information, medical and other service referrals, and other non-clinical information with WWH Legal Services to allow for legal referrals and for scheduling purposes. The details of my health records will only be shared with WWH lawyers if I agree for them to take my legal case.\\n\u00a0\\nHEALTH INFORMATION EXCHANGE AND PDMP\\nI understand that WWH participates in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange (HIE) and the Capital Partners in Care (CPC) HIE. These HIEs provide a way of sharing my health information among participating doctors\u2019 offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. I have been informed that my health information, including information relating to the mental health services I receive at WWH, will be shared with the HIEs in order to better coordinate my care and assist providers and public health officials in making more informed decisions. I have been advised by WWH that I have the right to \u201copt-out\u201d of the HIEs at any time. I understand that I can request a copy of WWH\u2019s \u201copt-out\u201d form and direct WWH to disable access to my health information, except to the extent that disclosure of such information is permitted or mandated by law. \\nI also acknowledge that it may be necessary for my Whitman-Walker Health provider to obtain information about my medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.\\n\u00a0\\nPatient Rights and Responsibilities\\nI have been given a copy of the WWH Rights and Responsibilities document and understand that both WWH and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint or grievance with WWH, as described on the WWH website and in the Patient Feedback notice posted on bulletin boards at the health center. I also understand that WWH has a Patient Handbook that contains information about being a patient at WWH including services offered, hours of operation and contact information.\\n\u00a0\\nRELEASE OF INFORMATION FOR BILLING AND CONSENT TO REIMBURSE\\nI know that WWH needs to send parts of my personal health information to organizations that help pay for my care, such as my insurance company or an organization that grants money to WWH. I allow WWH to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act (HIPAA).\\n\u00a0\\nCONSENT TO COMMUNICATIONS VIA E-COMMUNICATIONS\\nThe U. S. Department of Health and Human Services permits patients to request electronic communications with their providers. I acknowledge that the most secure means of communicating with WWH is by use of the patient portal. Any other method of communicating electronically presents a greater risk of breach of privacy because the communications may be intercepted by third parties or transmitted to unintended parties. WWH will make an effort to limit the information it includes in e-communications with me. I understand, however, that information about my medical care (including appointments, billing information, prescriptions and test results) may be sent to me electronically. By signing below, I am choosing and consenting freely to electronic communications. If I wish to discontinue e-communications with WWH, I can submit an E-communications Opt-Out Form available from Client Services or on the WWH website.\\n\u00a0\\nACKNOWLEDGMENT OF DUTY TO REIMBURSE WWH FOR HEALTH CARE SERVICES\\nI understand that WWH offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay based on their level of income. In order to be eligible for WWH\u2019s Sliding Fee Scale of discounted or free services, I will need to provide WWH\u2019s Public Benefits and Insurance Navigation team with documents establishing that I meet income eligibility requirements. If I do not provide the required documents to WWH, I am responsible for paying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service. I also understand that if I am an insured patient with insurance WWH does not accept, or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid.\\n\u00a0\\nBy signing my name below, I am acknowledging that I have read, and fully understand, each of the separate paragraphs set forth above.\",\"type\":\"control_text\"},null,null,{\"name\":\"clickTo323\",\"qid\":\"323\",\"text\":\"Patient Acknowledgement of Financial Obligation\",\"type\":\"control_text\"},null,{\"name\":\"clickTo325\",\"qid\":\"325\",\"text\":\"PREAMBLE\\nWhitman-Walker Health (&ldquo;WWH&rdquo;) is a Federally Qualified Health Center (&ldquo;FQHC&rdquo; or &ldquo;Health Center&rdquo;) that is subject to Section 330 of the Public Health Service Act. Section 330 specifies that Health Centers must assure that no patient will be denied services due to their inability to pay for such services. It also requires Health Centers to adopt written policies and procedures to maximize collections and reimbursement for their costs in providing health services.\\n&nbsp;&nbsp;\\nI UNDERSTAND THAT I AM RESPONSIBLE FOR:\\n\\nContributing to the cost of my care and treatment as my health insurance coverage requires and based on my ability to pay;\\nProviding WWH with the information it needs to receive reimbursement for the treatment or services it provides to me;\\nRequesting consideration for discounted fees under WWH&rsquo;s Sliding Fee Scale based on my level of income, and providing documentation to support eligibility for discounted fees that may be requested by WWH&rsquo;s Public Benefits and Insurance Navigation team;\\nAssisting the Public Benefits and Insurance Navigators with any application for insurance or public benefits that I may be entitled to;\\nPaying my co-payment (if applicable) when I check-in for my appointment and paying my deductible or any other fees that may be owed at the conclusion of the medical visit;\\nPaying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service, either upon check-in or at check-out as requested by WWH if I have been deemed a self-pay patient based on the fact that I have insurance coverage that WWH does not accept but have elected to remain in care at WWH.\\n\\nI understand that if I am an insured self-pay patient or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid. If I fail to pay my outstanding fees or copays in 30 days, WWH presumes that you are transitioning your care to another provider. If you have a health care issue requiring immediate care during the next 30 days, you may contact WWH and your provider will determine whether you should be seen. To prevent you from running out of medications, a thirty (30) day renewal will be made available if needed.\",\"type\":\"control_text\"},null,{\"name\":\"submit\",\"qid\":\"327\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"name\":\"clickTo328\",\"qid\":\"328\",\"text\":\"\\nAS A WWH PATIENT, YOU HAVE THE RIGHT TO:\\nACCESS SERVICES in a safe and respectful manner\\n\\nReceive services at WWH regardless of your race, color, religion, sex, marital status, sexual orientation, gender identity or expression, English language proficiency, national origin, age, disability, veteran status, or any other status protected by law.\\n\\n\\n\\nReceive respect and consideration from every employee, volunteer or trainee you interact with at WWH.\\n\\n\\nFeel safe from harm and free from verbal, physical, or psychological abuse, intimidation or harassment when you are at WWH\u2019s facilities.\\n\\n\\nPRIVACY regarding your personal health information\\n\\n\\nExpect WWH to comply with the Federal and State privacy laws when using or disclosing information about you or the health care and related services you receive at WWH.\\n\\n\\nReceive a copy of WWH\u2019s Notice of Privacy Practices when you register as a new patient so that you will be more fully informed about your privacy rights.\\n\\n\\nActive involvement in your ongoing care\\n\\n\\nHelp WWH providers and staff to develop a plan for the treatment and services you receive at WWH.\\n\\n\\nProvide (or withhold) your consent to voluntary treatment, including your participation in clinical research, and be informed about the consequences of refusing any treatment or service.\\n\\n\\nProvide WWH staff members with positive or negative feedback about your care, or voice your concerns or complaints about the Health Center.\\n\\n\\nTIMELY INFORMATION about your care\\n\\n\\nReceive complete information about your diagnosis, and treatment or service plan in plain language that you can understand.\\n\\n\\nObtain a copy of your medical records upon request unless the law permits WWH to withhold the records.\\n\\n\\nReceive an explanation of the costs associated with your care at WWH.\\n\\n\\nObtain assistance with referrals to other providers.\\n\\n\\nQUALITY SERVICES from our health center\\n\\n\\nReceive coordinated health care treatment and services consistent with professional standards.\\n\\n\\nReceive services from licensed and credentialed WWH providers.\\n\\n\\nRequest WWH to provide hearing, language, literacy or other communication assistance required by law.\\n\\n\\nReceive services and care in the least restrictive environment feasible, free from chemical or physical restraints.\\n\\n\\n\\n\\nAS A WWH PATIENT, YOU ARE RESPONSIBLE FOR:\\nYOUR PERSONAL INTERACTIONS with our health center team\\n\\nTreat WWH employees, volunteers, trainees, contractors, other patients, and guests with respect at all times.\\nDo not make any threatening or offensive statements at WWH\u2019s facilities.\\nDo not engage in any act of physical violence or other threatening or inappropriate behavior at WWH\u2019s facilities, which includes bringing a weapon of any kind on site.\\nDo not distribute or use alcohol or drugs on WWH\u2019s property or enter a WWH facility or program under the influence of illegal drugs or alcohol.\\n\\nACTIVE ENGAGEMENT in your care\\n\\nTake an active part in your treatment or service plan at WWH and stay in contact with your providers about your care.\\nRequest any hearing, language, literacy or other communications assistance you may need at least 48 hours prior to your visit.\\nShow up for your appointments at least 15 minutes ahead of schedule and provide advance notice whenever it becomes necessary to cancel an appointment at WWH.\\nContribute to the cost of your care that the law or the health plan that you participate in require you to pay.\\n\\nTIMELY INFORMATION sharing\\n\\n\\nProvide WWH with complete, accurate, and truthful information at all times.\\nWWH\u2019s Patient Rights and Responsibilities Policy grants WWH discretion to take action placing limits on a patient\u2019s ability to receive treatment or services at WWH based on a patient\u2019s failure to meet their Responsibilities or for any other reason permitted by law. Likewise, any WWH patient has discretion to decide not to seek further treatment or services at WWH based on WWH\u2019s failure to abide by the patient Rights set forth in this Statement or for any other reason.\\n\\n\\n\",\"type\":\"control_text\"},{\"name\":\"clickTo329\",\"qid\":\"329\",\"text\":\"Patient Rights and Responsibilities Statement\",\"type\":\"control_text\"},null,{\"name\":\"divider331\",\"qid\":\"331\",\"type\":\"control_divider\"},null,{\"name\":\"clickTo333\",\"qid\":\"333\",\"text\":\"Notice of Privacy Practices\",\"type\":\"control_text\"},{\"name\":\"clickTo334\",\"qid\":\"334\",\"text\":\"\\nThis Notice describes how medical information about you may&nbsp;be used and disclosed by Whitman-Walker Health (WWH) and&nbsp;how you can get access to this information. Please review it&nbsp;carefully.\\nYOUR RIGHTS\\nYou have the right to:\\n\\nGet a copy of your paper or electronic medical record\\nCorrect your paper or electronic medical record\\nRequest confidential communications\\nAsk us to limit the information about you that we share\\nGet a list of those with whom we&rsquo;ve shared your information\\nGet a copy of this Notice of Privacy Practices\\nChoose someone to act as your personal representative for purposes of your health information\\nFile a complaint if you believe your privacy rights have been violated\\n\\nYOUR CHOICES\\nYou have some choices in the way that we use and share information as we:\\n\\nTell family and friends about your health\\nProvide disaster relief\\nProvide mental health care\\nMarket our services and sell your information\\nRaise funds\\n\\nOUR USES AND DISCLOSURES\\nWe may use and share your information as we:\\n\\nTreat you\\nRun our organization\\nBill for your services\\nHelp with public health and safety issues\\nDo research\\nComply with the law\\nRespond to organ and tissue donation requests\\nWork with a medical examiner or funeral director\\nAddress workers&rsquo; compensation, law enforcement, and other government requests\\nRespond to lawsuits and legal actions\\n\\nA more detailed description of your rights, your choices and our uses and disclosures of your health information is set forth below:\\n&nbsp;\\nYOUR RIGHTS\\nWhen it comes to your health information, you have certain rights. This section of our Notice of Privacy Practices explains your rights and some of our responsibilities under the law.\\nGet an electronic or paper copy of your medical record.\\n\\nYou can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.\\nWe will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.\\nYou can ask us to correct health information about you that you think is incorrect or incomplete.\\n\\nAsk us to amend your medical record\\nWe may say &ldquo;no,&rdquo; but we&rsquo;ll tell you why in writing within 60 days In these cases we generally do not share your information unless you give us written permission:\\n\\nMarketing purposes\\nSale of your information\\nMost sharing of psychotherapy notes\\n\\nIn the case of fundraising:\\n\\nWe may contact you for fundraising efforts, but you can tell us not to contact you again.\\n\\nOUR USES AND DISCLOSURES OF INFORMATION ABOUT YOU\\nHow do we typically use or share your health information?\\nWe typically use or share your health information in the following ways.\\nTo treat you\\nWe can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.\\nTo run our organization\\nWe can use and share your health information to run our health center, improve your care, and contact you when necessary. Example: We use health information about you to improve the quality of care we provide to you and others.\\nIn order to bill for your services\\nWe can use and share your health information to bill and get payment from health plans or other entities. Example: We can give information about you to your health\\ninsurance plan in order to be paid for the services you receive at the health center.\\nHOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?\\nWe are allowed or required to share your information in other ways&mdash;usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. If you want to learn more you can go to: www.hhs.gov\\u002Focr\\u002Fprivacy\\u002Fhipaa\\u002Funderstanding\\u002Fconsumers\\u002Findex.html\\nHelp with public health and safety issues\\nWe can share health information about you for certain situations such as:\\n\\nPreventing disease\\nHelping with product recalls\\nReporting adverse reactions to medications\\nReporting suspected abuse, neglect, or domestic violence\\nPreventing or reducing a serious threat to anyone&rsquo;s health or safety\\n\\n&nbsp;\\nRequest confidential communications\\nMake a reasonable request to contact you in a specific way (for example, home or office phone) or to send mail to a different address.Ask us to limit what we use or share\\nYou can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say &ldquo;no&rdquo; if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say &ldquo;yes&rdquo; unless a law requires us to share that information.&nbsp;\\n\\n\\nDo research\\nWe can use or share your information for health research.\\nComply with the law\\nWe will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we&rsquo;re complying with federal privacy la\\nGet a list of those with whom we&rsquo;ve shared information\\n\\nYou can ask for a list (accounting) of the times we&rsquo;ve shared your health information for six years prior to the date you ask, who we shared it with, and why.\\nWe will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We&rsquo;ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.\\n\\nGet a copy of this Notice of Privacy Practices\\n\\nYou can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically and we will provide you with a paper copy promptly.\\n\\nChoose someone to act for you\\n\\nIf you have given someone health care power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.\\nOur Legal Services Department can assist you with the preparation of a health care power of attorney document that provides authority for another person to act on your behalf.\\n\\nFile a complaint if you feel your rights are violated\\n\\nYou can complain if you feel we have violated your rights by contacting Whitman-Walker&rsquo;s Privacy Officer at 202.939.7694.\\nYou can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington, DC 20201, calling 1.877. 696.6775, or visiting www.hhs.gov\\u002Focr\\u002Fprivacy\\u002Fhipaa\\u002Fcomplaints.\\nWe will not retaliate against you for filing a complaint.\\n\\nYOUR CHOICES\\nFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:\\n\\nShare information with your family, close friends, or others involved in your care\\nShare information in a disaster relief situation\\n\\nIf you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.\\nRespond to organ and tissue donation requests\\nWe can share health information about you with organ procurement organizations.\\nWork with a medical examiner or funeral director\\nWe can share health information about a deceased patient with a coroner, medical examiner, or funeral director.\\nAddress workers&rsquo; compensation, law enforcement, and other&nbsp;government requests.\\nWe can use or share health information about you:\\n\\nFor workers&rsquo; compensation claims\\nFor law enforcement purposes or with a law enforcement official\\nWith health oversight agencies for activities authorized by law\\nFor special government functions such as military, national security, and presidential protective services\\n\\nRespond to lawsuits and legal actions\\nWe can share health information about you in response to a court or administrative order, or in response to a subpoena.\\nOUR RESPONSIBILITIES\\n\\nWe are required by law to maintain the privacy and security of your protected health information.\\nWe will let you know in writing if a breach occurs that may have compromised the privacy or security of your information.\\nWe must follow the duties and privacy practices described in this Notice and give you a copy of it.\\nWe will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.\\nWe do not share records relating to your participation in a WWH substance abuse program or your mental health records with providers outside of WWH without your written authorization.\\n\\nThe original effective date of this Notice is April 14, 2003 and the Notice was most recently updated on September 24, 2019. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice of Privacy Practices will be available upon request, in our office, and on our web site.\\nWWH is participating in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange and the Capital Partners in Care (CPC) Health Information Exchange. These health information exchanges (HIEs) provide a way of sharing your health information among participating doctors&rsquo; offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. As permitted by DC Mental Health Information Amendment Act of 2018, your mental health information will be shared with the CPC and CRISP HIEs to provide faster access, better coordination of care, and improved knowledge for providers. If you do not want your mental health information to be shared among your providers, you have the right to opt-out of the HIEs at any time by completing an Opt-Out Form available at the Front Desk. Note, however, that it is not possible to share some but not all of your health and mental health information. If you opt-out of one or both HIEs, none of your health information will be shared with that HIE for purposes of coordinating your care and treatment. It may also necessary for your Whitman-Walker Health provider to obtain information about your medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.\\nAcknowledgement of receipt of this Notice of Privacy Practices is indicated by your signature on our Informed Consent Form that is scanned into your electronic medical record.\\n\",\"type\":\"control_text\"},null,null,{\"name\":\"divider337\",\"qid\":\"337\",\"type\":\"control_divider\"},{\"name\":\"divider338\",\"qid\":\"338\",\"type\":\"control_divider\"},{\"name\":\"input339\",\"qid\":\"339\",\"text\":\"Telehealth\\n\u00a0\\nCONSENT TO RECEIVE MEDICAL, DENTAL AND BEHAVIORAL HEALTH SERVICES VIA TELEHEALTH\\nThis form gives you facts about, and risks of, telehealth services.\\nBy signing this form, or verbally agreeing to its terms, you consent to receive telehealth services and treatment by a Whitman-Walker Health medical, dental or behavioral health provider, and you acknowledge your understanding and agreement to the following:\\n\\nYou will be participating in a medical, dental or behavioral health telehealth visit at a location different from where your Whitman-Walker Health provider is located, which may limit the ability of your provider to provide medical care. For example, your provider will not be able to conduct an in-person physical examination and cannot provide emergency medical services during a telehealth visit.\\nIt is the role of your provider to determine whether or not the condition you are being diagnosed with or treated for is appropriate for a telehealth visit.\\nYou or your provider may require an in-person examination before or after diagnosing or prescribing a treatment plan.\\nIf you are experiencing a medical or mental health emergency, you understand you will be asked to immediately call 911 or go to the nearest emergency room.\\nThis telehealth visit and future telehealth visits will be conducted with the use of real-time interactive two-way audio, video or other electronic communications. Whitman-Walker Health has taken steps to protect the security of information disclosed during the session, but Internet security and privacy are not guaranteed. You understand that (1) security protocols could fail, potentially causing a breach of your protected health information, (2) information you transmit through telehealth technology may be insufficient to allow for appropriate medical decision-making by your provider (for example, poor image resolution); or (3) failures of equipment (for example, servers, devices) or infrastructure (for example, communications lines, power supply) may cause delays in medical evaluation and treatment, or loss of information, and you agree to hold Whitman-Walker Health harmless for any loss of protected health information that occurs due to technological failure.\\nWhitman-Walker Health will need to obtain an accurate medical and mental health history, condition(s) and description of current or previous medical or mental health care from you during telehealth sessions to best support diagnosis, therapy, follow-up and\\u002For education.\\nYour provider may have other medical staff participate in your telehealth visit and you agree to medical staff participation. You have the right, at any time, to request the medical staff to leave the telehealth visit.\\nIf you allow another person to participate in your telehealth visit (e.g., family, caregiver), you consent to their participation.\\nWhitman-Walker Health may share your identifiable information from your telehealth visits with third parties, except as prohibited by law. Whitman-Walker Health may separately request your consent to share identifiable information from your telehealth visits with third parties, as necessary.\\nThere are potential risks to telehealth, such as technological interruptions, unauthorized access, and technical difficulties. Your provider will obtain or confirm your contact information in order to reach you in the event of a technical issue.\\nYou or your provider can stop any telehealth visit if either of you feel that the videoconferencing connections are not adequate for the situation.\\nHaving a telehealth visit is your choice. Even if you have agreed to the session, you can change your mind about participating in this or future telehealth sessions. You have the right to withdraw your consent.\\n\\nBY SIGNING YOUR NAME BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ (OR HAVE HAD READ TO YOU), AND UNDERSTAND EACH OF THE SEPARATE PARAGRAPHS ABOVE, YOU HAVE HAD A CHANCE TO ASK WHITMAN-WALKER HEALTH STAFF ANY QUESTIONS YOU MAY HAVE, AND YOU CONSENT TO THE TELEHEALTH SERVICES AND TREATMENT PROVIDED TO YOU BY WHITMAN-WALKER HEALTH.\\nThis Consent lasts for as long as telehealth services continue, unless you exercise your right to withdraw your consent at any time.\\nIf you are not able to place a wet signature or electronic signature on this Consent and return it to Whitman-Walker Health, you will verbally inform Whitman-Walker Health that you have reviewed this form and provide your verbal consent. Whitman-Walker Health will document your consent to telehealth services in your electronic medical record.\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"typeA340\",\"qid\":\"340\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"attachInsurance\",\"qid\":\"341\",\"subLabel\":\"*Max 2 files front &amp; back (JPG, PNG, PDF)\",\"text\":\"Attach Insurance ID\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"input342\",\"qid\":\"342\",\"subLabel\":\"*Max 2 files, front and back (JPG, PNG, PDF)\",\"text\":\"Attach Insurance ID\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"input343\",\"qid\":\"343\",\"subLabel\":\"*JPG, PNG, PDF\",\"text\":\"Attach Your Current Photo ID\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"nameOf\",\"qid\":\"344\",\"subLabel\":\"\",\"text\":\"Name of Patient:\",\"type\":\"control_textbox\"},null,{\"description\":\"\",\"name\":\"date346\",\"qid\":\"346\",\"text\":\"Date of Birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"signature347\",\"qid\":\"347\",\"subLabel\":\"\",\"text\":\"Signature\",\"type\":\"control_signature\"},null,{\"description\":\"\",\"name\":\"typeA349\",\"qid\":\"349\",\"subLabel\":\"\",\"text\":\"Patient Location for telehealth visits (list state): \",\"type\":\"control_textbox\"},null,null,null,null,null,null,{\"description\":\"\",\"name\":\"signature356\",\"qid\":\"356\",\"subLabel\":\"\",\"text\":\"Signature\",\"type\":\"control_signature\"},{\"description\":\"\",\"name\":\"signature\",\"qid\":\"357\",\"subLabel\":\"\",\"text\":\"Signature\",\"type\":\"control_signature\"},{\"description\":\"\",\"name\":\"signature358\",\"qid\":\"358\",\"subLabel\":\"\",\"text\":\"Signature\",\"type\":\"control_signature\"},{\"description\":\"\",\"name\":\"date\",\"qid\":\"359\",\"text\":\"Date\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"date360\",\"qid\":\"360\",\"text\":\"Date of Birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"tags\",\"qid\":\"361\",\"text\":\"Tags\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"familySize362\",\"qid\":\"362\",\"subLabel\":\"\",\"text\":\"Family Size\",\"type\":\"control_dropdown\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/hipaa.jotform.com\/submit\/90855390132456\/\" method=\"post\" enctype=\"multipart\/form-data\" name=\"form_90855390132456\" id=\"90855390132456\" accept-charset=\"utf-8\" autocomplete=\"off\">\n  <input type=\"hidden\" name=\"formID\" value=\"90855390132456\" \/>\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <link type=\"text\/css\" rel=\"stylesheet\" media=\"all\" href=\"https:\/\/cdn.jotfor.ms\/wizards\/languageWizard\/custom-dropdown\/css\/lang-dd.css?3.3.25229\" \/>\n    <div class=\"cont\">\n      <input type=\"text\" id=\"input_language\" name=\"input_language\" style=\"display:none\" \/>\n      <div class=\"language-dd\" id=\"langDd\" style=\"display:none\">\n        <div class=\"dd-placeholder lang-emp\">\n          Language\n        <\/div>\n        <ul class=\"lang-list dn\" id=\"langList\">\n          <li data-lang=\"en\" class=\"en\">\n            English (US)\n          <\/li>\n          <li data-lang=\"es-419\" class=\"es-419\">\n            Spanish (Latin America)\n          <\/li>\n        <\/ul>\n      <\/div>\n    <\/div>\n    <script type=\"text\/javascript\" src=\"https:\/\/cdn.jotfor.ms\/js\/formTranslation.v2.js?3.3.25229\"><\/script>\n    <ul class=\"form-section page-section\">\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_313\">\n        <div id=\"cid_313\" class=\"form-input-wide\">\n          <div id=\"text_313\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 14pt;\">Welcome to Whitman-Walker Health! We look forward to you joining our healthcare family. Incorporated in 1978,<\/span><span style=\"font-size: 14pt;\">\u00a0Whitman-Walker Health is a nonprofit community health center focused on removing barriers\u00a0<\/span><span style=\"font-size: 14pt;\">to accessing care in the Washington, DC, metropolitan area. Whitman-Walker works to provide stigma-free\u00a0<\/span><span style=\"font-size: 14pt;\">healthcare and support services to the gay, lesbian, bisexual, transgender and non-binary communities of greater\u00a0<\/span><span style=\"font-size: 14pt;\">Washington, and people living with or affected by HIV. Through multiple locations in the district, Whitman-Walker\u00a0<\/span><span style=\"font-size: 14pt;\">serves 20,000 individuals with medical and dental care, mental health and addiction services, legal services, youth\u00a0<\/span><span style=\"font-size: 14pt;\">programming and more. We extend affirmation, dignity and respect to everyone we provide care to.<\/span><\/p>\n            <p><br \/><strong><span style=\"font-size: 14pt;\">This packet includes the following:<\/span><\/strong><\/p>\n            <ul>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  Patient Registration\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  Consents and Acknowledgement\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  Patient Acknowledgement of Financial Obligation\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  Patient Rights and Responsibilities Statement\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  Notice of Privacy Practices\n                <\/span>\n              <\/li>\n            <\/ul>\n            <p><strong><span style=\"font-size: 14pt;\">You might be wondering why it\u2019s important for you to completely fill out your registration form.\u00a0<\/span><span style=\"font-size: 14pt;\">Here\u2019s why:<\/span><\/strong><\/p>\n            <ul>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  The information you provide helps us learn about you and better serve you. This information includes\u00a0\n                <\/span>\n                <span style=\"font-size: 14pt;\">\n                  your preferred name and gender pronouns.\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  It also helps us comply with grants we apply for and provide services through. To keep receiving grant\u00a0\n                <\/span>\n                <span style=\"font-size: 14pt;\">\n                  funding and serve you affordable care, we need for you to answer all questions on the form, including\u00a0\n                <\/span>\n                <span style=\"font-size: 14pt;\">\n                  information about your annual income, family size, and housing.\n                <\/span>\n              <\/li>\n            <\/ul>\n            <p><br \/><strong><span style=\"font-size: 14pt;\">This information will become a part of your health record. It is kept confidential. It is protected by\u00a0<\/span><span style=\"font-size: 14pt;\">law just like all of your health information.<\/span><\/strong><\/p>\n            <p><br \/><span style=\"font-size: 14pt;\">Thank you for choosing Whitman-Walker Health for your healthcare needs and for taking time to complete these\u00a0<\/span><span style=\"font-size: 14pt;\">forms. We appreciate you!<\/span><\/p>\n            <p><span style=\"font-size: 14pt;\">Sincerely,<\/span><\/p>\n            <p><span style=\"font-size: 14pt;\">Sarah Henn, MD<br \/>Chief Health Officer<\/span><\/p>\n            <p>\u00a0<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_311\">\n        <div id=\"cid_311\" class=\"form-input-wide\">\n          <div id=\"text_311\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 14pt;\"><strong>Welcome to Whitman-Walker Health!<\/strong> We are happy you have chosen us for your care. To register, please complete this\u00a0<\/span><span style=\"font-size: 14pt;\">form. Several of the items below help us ensure that we are meeting the needs of the population we serve, so please be\u00a0<\/span><span style=\"font-size: 14pt;\">as thorough as you can. Let us know if you have any questions or if you need help in completing this form.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_236\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-small\">\n          <div class=\"header-text httal htvam\">\n            <h3 id=\"header_236\" class=\"form-header\" data-component=\"header\">\n              HOW CAN WE HELP YOU?\n            <\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_237\">\n        <label class=\"form-label form-label-top\" id=\"label_237\" for=\"input_237\">  <\/label>\n        <div id=\"cid_237\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_237\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_0\" name=\"q237_input237[]\" value=\"Primary Medical Care\" \/>\n              <label id=\"label_input_237_0\" for=\"input_237_0\"> Primary Medical Care <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_1\" name=\"q237_input237[]\" value=\"HIV Testing\" \/>\n              <label id=\"label_input_237_1\" for=\"input_237_1\"> HIV Testing <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_2\" name=\"q237_input237[]\" value=\"STI Testing\" \/>\n              <label id=\"label_input_237_2\" for=\"input_237_2\"> STI Testing <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_3\" name=\"q237_input237[]\" value=\"Dental\" \/>\n              <label id=\"label_input_237_3\" for=\"input_237_3\"> Dental <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_4\" name=\"q237_input237[]\" value=\"Gender-Affirming Care\" \/>\n              <label id=\"label_input_237_4\" for=\"input_237_4\"> Gender-Affirming Care <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_5\" name=\"q237_input237[]\" value=\"Support Groups\" \/>\n              <label id=\"label_input_237_5\" for=\"input_237_5\"> Support Groups <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_6\" name=\"q237_input237[]\" value=\"Legal Services\" \/>\n              <label id=\"label_input_237_6\" for=\"input_237_6\"> Legal Services <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_7\" name=\"q237_input237[]\" value=\"Aesthetics\" \/>\n              <label id=\"label_input_237_7\" for=\"input_237_7\"> Aesthetics <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_8\" name=\"q237_input237[]\" value=\"Substance Abuse Services\" \/>\n              <label id=\"label_input_237_8\" for=\"input_237_8\"> Substance Abuse Services <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_9\" name=\"q237_input237[]\" value=\"Pre-Exposure Prophylaxis (PrEP)\" \/>\n              <label id=\"label_input_237_9\" for=\"input_237_9\"> Pre-Exposure Prophylaxis (PrEP) <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_10\" name=\"q237_input237[]\" value=\"HIV Medical Care\/Red Carpet\" \/>\n              <label id=\"label_input_237_10\" for=\"input_237_10\"> HIV Medical Care\/Red Carpet <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_237_11\" name=\"q237_input237[]\" value=\"Post-Exposure Prophylaxis (PEP) (I believe I was exposed to HIV)\" \/>\n              <label id=\"label_input_237_11\" for=\"input_237_11\"> Post-Exposure Prophylaxis (PEP) (I believe I was exposed to HIV) <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_255\">\n        <div id=\"cid_255\" class=\"form-input-wide\">\n          <div id=\"text_255\" class=\"form-html\" data-component=\"text\">\n            <p>Wellness services available for existing eligible patients:<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_256\">\n        <label class=\"form-label form-label-top\" id=\"label_256\" for=\"input_256\">  <\/label>\n        <div id=\"cid_256\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_256\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_0\" name=\"q256_input256[]\" value=\"Acupuncture\" \/>\n              <label id=\"label_input_256_0\" for=\"input_256_0\"> Acupuncture <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_1\" name=\"q256_input256[]\" value=\"Diabetes Education\" \/>\n              <label id=\"label_input_256_1\" for=\"input_256_1\"> Diabetes Education <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_2\" name=\"q256_input256[]\" value=\"Massage Therapy\" \/>\n              <label id=\"label_input_256_2\" for=\"input_256_2\"> Massage Therapy <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_3\" name=\"q256_input256[]\" value=\"Nutrition\" \/>\n              <label id=\"label_input_256_3\" for=\"input_256_3\"> Nutrition <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_4\" name=\"q256_input256[]\" value=\"Reiki\" \/>\n              <label id=\"label_input_256_4\" for=\"input_256_4\"> Reiki <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_5\" name=\"q256_input256[]\" value=\"Psychiatry\" \/>\n              <label id=\"label_input_256_5\" for=\"input_256_5\"> Psychiatry <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_6\" name=\"q256_input256[]\" value=\"Smoking Cessation\" \/>\n              <label id=\"label_input_256_6\" for=\"input_256_6\"> Smoking Cessation <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_7\" name=\"q256_input256[]\" value=\"Yoga\" \/>\n              <label id=\"label_input_256_7\" for=\"input_256_7\"> Yoga <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_256_8\" name=\"q256_input256[]\" value=\"Mental Health Counseling\" \/>\n              <label id=\"label_input_256_8\" for=\"input_256_8\"> Mental Health Counseling <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_238\">\n        <div id=\"cid_238\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_234\">\n        <label class=\"form-label form-label-left\" id=\"label_234\" for=\"first_234\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_234\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\" class=\"extended\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_234\" name=\"q234_name[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_234 sublabel_234_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_234\" id=\"sublabel_234_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"middle\">\n              <input type=\"text\" id=\"middle_234\" name=\"q234_name[middle]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"middle\" aria-labelledby=\"label_234 sublabel_234_middle\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"middle_234\" id=\"sublabel_234_middle\" style=\"min-height:13px\" aria-hidden=\"false\"> Middle Initial <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_234\" name=\"q234_name[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_234 sublabel_234_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_234\" id=\"sublabel_234_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_239\">\n        <label class=\"form-label form-label-left\" id=\"label_239\" for=\"input_239\"> I go by (Name): <\/label>\n        <div id=\"cid_239\" class=\"form-input\">\n          <input type=\"text\" id=\"input_239\" name=\"q239_iGo\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"40\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_239\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_360\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_360\" for=\"lite_mode_360\">\n          Date of Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_360\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_360\" name=\"q360_date360[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_360 sublabel_360_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_360\" id=\"sublabel_360_month\" style=\"min-height:13px\" aria-hidden=\"false\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_360\" name=\"q360_date360[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_360 sublabel_360_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_360\" id=\"sublabel_360_day\" style=\"min-height:13px\" aria-hidden=\"false\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_360\" name=\"q360_date360[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_360 sublabel_360_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_360\" id=\"sublabel_360_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_360\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"mm-dd-yyyy\" autoComplete=\"off\" aria-labelledby=\"label_360\" \/>\n              <img class=\"showAutoCalendar newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_360_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v1\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_360\" id=\"sublabel_360_litemode\" style=\"min-height:13px\" aria-hidden=\"false\">  <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_242\">\n        <label class=\"form-label form-label-left\" id=\"label_242\" for=\"input_242\"> Social Security Number <\/label>\n        <div id=\"cid_242\" class=\"form-input\">\n          <input type=\"text\" id=\"input_242\" name=\"q242_socialSecurity\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_242\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_101\">\n        <div id=\"cid_101\" class=\"form-input-wide\">\n          <div id=\"text_101\" class=\"form-html\" data-component=\"text\">\n            <hr \/>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_240\">\n        <div id=\"cid_240\" class=\"form-input-wide\">\n          <div id=\"text_240\" class=\"form-html\" data-component=\"text\">\n            <p>Whitman-Walker will send you mail to the listed address. We believe it is important to communicate with you, and at times, we do mail information.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_4\">\n        <label class=\"form-label form-label-left\" id=\"label_4\" for=\"input_4_addr_line1\">\n          Address:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input jf-required\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_4_addr_line1\" name=\"q4_address4[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_4 sublabel_4_addr_line1\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_4_addr_line1\" id=\"sublabel_4_addr_line1\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_4_addr_line2\" name=\"q4_address4[addr_line2]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_4 sublabel_4_addr_line2\" \/>\n                  <label class=\"form-sub-label\" for=\"input_4_addr_line2\" id=\"sublabel_4_addr_line2\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-city-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_4_city\" name=\"q4_address4[city]\" class=\"form-textbox validate[required] form-address-city\" value=\"\" data-component=\"city\" aria-labelledby=\"label_4 sublabel_4_city\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_4_city\" id=\"sublabel_4_city\" style=\"min-height:13px\" aria-hidden=\"false\"> City <\/label>\n                <\/span>\n              <\/span>\n              <span class=\"form-address-line form-address-state-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_4_state\" name=\"q4_address4[state]\" class=\"form-textbox validate[required] form-address-state\" value=\"\" data-component=\"state\" aria-labelledby=\"label_4 sublabel_4_state\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_4_state\" id=\"sublabel_4_state\" style=\"min-height:13px\" aria-hidden=\"false\"> State \/ Province <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-zip-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_4_postal\" name=\"q4_address4[postal]\" class=\"form-textbox validate[required] form-address-postal\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_4 sublabel_4_postal\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_4_postal\" id=\"sublabel_4_postal\" style=\"min-height:13px\" aria-hidden=\"false\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_241\">\n        <label class=\"form-label form-label-left\" id=\"label_241\" for=\"input_241\">\n          Is your housing\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_241\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_241\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_241_0\" name=\"q241_isYour\" value=\"Stable\" required=\"\" \/>\n              <label id=\"label_input_241_0\" for=\"input_241_0\"> Stable <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_241_1\" name=\"q241_isYour\" value=\"Unstable\" required=\"\" \/>\n              <label id=\"label_input_241_1\" for=\"input_241_1\"> Unstable <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_241_2\" name=\"q241_isYour\" value=\"Temporary\" required=\"\" \/>\n              <label id=\"label_input_241_2\" for=\"input_241_2\"> Temporary <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_108\">\n        <div id=\"cid_108\" class=\"form-input-wide\">\n          <div id=\"text_108\" class=\"form-html\" data-component=\"text\">\n            <hr \/>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_245\">\n        <div id=\"cid_245\" class=\"form-input-wide\">\n          <div id=\"text_245\" class=\"form-html\" data-component=\"text\">\n            <p>The most secure way to communicate with us is via our patient portal. We will need your identification and an email to set up a patient portal account.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_225\">\n        <label class=\"form-label form-label-left\" id=\"label_225\" for=\"input_225\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_225\" class=\"form-input jf-required\">\n          <input type=\"email\" id=\"input_225\" name=\"q225_email\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" aria-labelledby=\"label_225\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_302\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_302\" for=\"input_302\">\n          Cell Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_302\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_302\" name=\"q302_cellNumber\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_302\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_303\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_303\" for=\"input_303\"> Home Number <\/label>\n        <div id=\"cid_303\" class=\"form-input\">\n          <input type=\"text\" id=\"input_303\" name=\"q303_homeNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_303\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_304\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_304\" for=\"input_304\"> Work Number <\/label>\n        <div id=\"cid_304\" class=\"form-input\">\n          <input type=\"text\" id=\"input_304\" name=\"q304_workNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_304\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_343\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_343\" for=\"input_343\"> Attach Your Current Photo ID <\/label>\n        <div id=\"cid_343\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Choose file\n              <\/div>\n              <input type=\"file\" id=\"input_343\" name=\"q343_input343[]\" multiple=\"\" class=\"form-upload-multiple\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, jpg, jpeg, png\" data-file-maxsize=\"10240\" data-file-minsize=\"0\" data-file-limit=\"1\" data-component=\"fileupload\" \/>\n              <label class=\"form-sub-label\" for=\"input_343\" style=\"min-height:13px\" aria-hidden=\"false\"> *JPG, PNG, PDF <\/label>\n            <\/span>\n            <span style=\"display:none\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_244\">\n        <div id=\"cid_244\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_250\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_250\" for=\"input_250\">\n          Gender Identity\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_250\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_250\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_250_0\" name=\"q250_genderIdentity\" value=\"Man\" required=\"\" \/>\n              <label id=\"label_input_250_0\" for=\"input_250_0\"> Man <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_250_1\" name=\"q250_genderIdentity\" value=\"Woman\" required=\"\" \/>\n              <label id=\"label_input_250_1\" for=\"input_250_1\"> Woman <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_250_2\" name=\"q250_genderIdentity\" value=\"Trans Man\" required=\"\" \/>\n              <label id=\"label_input_250_2\" for=\"input_250_2\"> Trans Man <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_250_3\" name=\"q250_genderIdentity\" value=\"Trans Woman\" required=\"\" \/>\n              <label id=\"label_input_250_3\" for=\"input_250_3\"> Trans Woman <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_250_4\" name=\"q250_genderIdentity\" value=\"Genderqueer\/Non-binary\" required=\"\" \/>\n              <label id=\"label_input_250_4\" for=\"input_250_4\"> Genderqueer\/Non-binary <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q250_genderIdentity\" id=\"other_250\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_250\" style=\"text-indent:0\" for=\"other_250\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q250_genderIdentity[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_250\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_251\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_251\" for=\"input_251\">\n          Sex at Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_251\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_251\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_251_0\" name=\"q251_sexAt\" value=\"Male\" required=\"\" \/>\n              <label id=\"label_input_251_0\" for=\"input_251_0\"> Male <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_251_1\" name=\"q251_sexAt\" value=\"Female\" required=\"\" \/>\n              <label id=\"label_input_251_1\" for=\"input_251_1\"> Female <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_251_2\" name=\"q251_sexAt\" value=\"Intersex\" required=\"\" \/>\n              <label id=\"label_input_251_2\" for=\"input_251_2\"> Intersex <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q251_sexAt\" id=\"other_251\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_251\" style=\"text-indent:0\" for=\"other_251\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q251_sexAt[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_251\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_252\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_252\" for=\"input_252\">\n          Do you identify as transgender?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_252\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_252\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_252_0\" name=\"q252_doYou252\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_252_0\" for=\"input_252_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_252_1\" name=\"q252_doYou252\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_252_1\" for=\"input_252_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_253\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_253\" for=\"input_253\">\n          Sexual Orientation\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_253\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_253\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_253_0\" name=\"q253_sexualOrientation\" value=\"Lesbian, Gay, Homosexual\" required=\"\" \/>\n              <label id=\"label_input_253_0\" for=\"input_253_0\"> Lesbian, Gay, Homosexual <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_253_1\" name=\"q253_sexualOrientation\" value=\"Straight, Heterosexual\" required=\"\" \/>\n              <label id=\"label_input_253_1\" for=\"input_253_1\"> Straight, Heterosexual <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_253_2\" name=\"q253_sexualOrientation\" value=\"Bisexual\" required=\"\" \/>\n              <label id=\"label_input_253_2\" for=\"input_253_2\"> Bisexual <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q253_sexualOrientation\" id=\"other_253\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_253\" style=\"text-indent:0\" for=\"other_253\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q253_sexualOrientation[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_253\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_254\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_254\" for=\"input_254\">\n          Gender Pronouns\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_254\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_254\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_254_0\" name=\"q254_genderPronouns\" value=\"He\/Him\/His\" required=\"\" \/>\n              <label id=\"label_input_254_0\" for=\"input_254_0\"> He\/Him\/His <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_254_1\" name=\"q254_genderPronouns\" value=\"She\/Her\/Hers\" required=\"\" \/>\n              <label id=\"label_input_254_1\" for=\"input_254_1\"> She\/Her\/Hers <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_254_2\" name=\"q254_genderPronouns\" value=\"They\/Them\/Theirs\" required=\"\" \/>\n              <label id=\"label_input_254_2\" for=\"input_254_2\"> They\/Them\/Theirs <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q254_genderPronouns\" id=\"other_254\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_254\" style=\"text-indent:0\" for=\"other_254\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q254_genderPronouns[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_254\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_257\">\n        <div id=\"cid_257\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_258\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_258\" for=\"input_258\">\n          Annual Family Income\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_258\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_258\" name=\"q258_annualFamily258\" data-type=\"input-textbox\" class=\"form-textbox validate[required, Numeric]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_258\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_362\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_362\" for=\"input_362\">\n          Family Size\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_362\" class=\"form-input jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_362\" name=\"q362_familySize362\" style=\"width:250px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_362\">\n            <option value=\"\">  <\/option>\n            <option value=\"1\"> 1 <\/option>\n            <option value=\"2\"> 2 <\/option>\n            <option value=\"3\"> 3 <\/option>\n            <option value=\"4\"> 4 <\/option>\n            <option value=\"5\"> 5 <\/option>\n            <option value=\"6\"> 6 <\/option>\n            <option value=\"7\"> 7 <\/option>\n            <option value=\"8\"> 8 <\/option>\n            <option value=\"9\"> 9 <\/option>\n            <option value=\"10+\"> 10+ <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden jf-required\" data-type=\"control_textbox\" id=\"id_259\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_259\" for=\"input_259\">\n          Family Size\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_259\" class=\"form-input always-hidden jf-required\">\n          <input type=\"text\" id=\"input_259\" name=\"q259_familySize\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_259\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_260\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_260\" for=\"input_260\">\n          Ethnicity\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_260\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_260\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_0\" name=\"q260_ethnicity[]\" value=\"Non-Hispanic\/Non-Latino\" required=\"\" \/>\n              <label id=\"label_input_260_0\" for=\"input_260_0\"> Non-Hispanic\/Non-Latino <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_1\" name=\"q260_ethnicity[]\" value=\"Mexican\" required=\"\" \/>\n              <label id=\"label_input_260_1\" for=\"input_260_1\"> Mexican <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_2\" name=\"q260_ethnicity[]\" value=\"Mexican American\" required=\"\" \/>\n              <label id=\"label_input_260_2\" for=\"input_260_2\"> Mexican American <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_3\" name=\"q260_ethnicity[]\" value=\"Chicano\/a\" required=\"\" \/>\n              <label id=\"label_input_260_3\" for=\"input_260_3\"> Chicano\/a <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_4\" name=\"q260_ethnicity[]\" value=\"Puerto Rican\" required=\"\" \/>\n              <label id=\"label_input_260_4\" for=\"input_260_4\"> Puerto Rican <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_5\" name=\"q260_ethnicity[]\" value=\"Cuban\" required=\"\" \/>\n              <label id=\"label_input_260_5\" for=\"input_260_5\"> Cuban <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_6\" name=\"q260_ethnicity[]\" value=\"Another Hispanic Latino\/a\" required=\"\" \/>\n              <label id=\"label_input_260_6\" for=\"input_260_6\"> Another Hispanic Latino\/a <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_260_7\" name=\"q260_ethnicity[]\" value=\"Spanish Origin\" required=\"\" \/>\n              <label id=\"label_input_260_7\" for=\"input_260_7\"> Spanish Origin <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_checkbox\" id=\"id_262\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_262\" for=\"input_262\">  <\/label>\n        <div id=\"cid_262\" class=\"form-input always-hidden\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_262\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_0\" name=\"q262_input262[]\" value=\"Mexican\" \/>\n              <label id=\"label_input_262_0\" for=\"input_262_0\"> Mexican <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_1\" name=\"q262_input262[]\" value=\"Mexican American\" \/>\n              <label id=\"label_input_262_1\" for=\"input_262_1\"> Mexican American <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_2\" name=\"q262_input262[]\" value=\"Chicano\/a\" \/>\n              <label id=\"label_input_262_2\" for=\"input_262_2\"> Chicano\/a <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_3\" name=\"q262_input262[]\" value=\"Puerto Rican\" \/>\n              <label id=\"label_input_262_3\" for=\"input_262_3\"> Puerto Rican <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_4\" name=\"q262_input262[]\" value=\"Cuban\" \/>\n              <label id=\"label_input_262_4\" for=\"input_262_4\"> Cuban <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_5\" name=\"q262_input262[]\" value=\"Another Hispanic Latino\/a\" \/>\n              <label id=\"label_input_262_5\" for=\"input_262_5\"> Another Hispanic Latino\/a <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_262_6\" name=\"q262_input262[]\" value=\"Spanish Origin\" \/>\n              <label id=\"label_input_262_6\" for=\"input_262_6\"> Spanish Origin <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_263\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_263\" for=\"input_263\"> Race <\/label>\n        <div id=\"cid_263\" class=\"form-input\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_263\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_263_0\" name=\"q263_race[]\" value=\"African American\/Black (including Africa, Caribbean)\" \/>\n              <label id=\"label_input_263_0\" for=\"input_263_0\"> African American\/Black (including Africa, Caribbean) <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_263_1\" name=\"q263_race[]\" value=\"Caucasian\/White (including Middle Eastern)\" \/>\n              <label id=\"label_input_263_1\" for=\"input_263_1\"> Caucasian\/White (including Middle Eastern) <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_263_2\" name=\"q263_race[]\" value=\"American Indian or Alaska Native\u00a0(including all Original Peoples of the Americas)\" \/>\n              <label id=\"label_input_263_2\" for=\"input_263_2\"> American Indian or Alaska Native\u00a0(including all Original Peoples of the Americas) <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_264\">\n        <div id=\"cid_264\" class=\"form-input-wide\">\n          <div id=\"text_264\" class=\"form-html\" data-component=\"text\">\n            <p>Asian (please specify)<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_265\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_265\" for=\"input_265\">  <\/label>\n        <div id=\"cid_265\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_265\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_0\" name=\"q265_typeA[]\" value=\"Asian Indian\" \/>\n              <label id=\"label_input_265_0\" for=\"input_265_0\"> Asian Indian <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_1\" name=\"q265_typeA[]\" value=\"Chinese\" \/>\n              <label id=\"label_input_265_1\" for=\"input_265_1\"> Chinese <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_2\" name=\"q265_typeA[]\" value=\"Filipino\" \/>\n              <label id=\"label_input_265_2\" for=\"input_265_2\"> Filipino <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_3\" name=\"q265_typeA[]\" value=\"Japanese\" \/>\n              <label id=\"label_input_265_3\" for=\"input_265_3\"> Japanese <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_4\" name=\"q265_typeA[]\" value=\"Korean\" \/>\n              <label id=\"label_input_265_4\" for=\"input_265_4\"> Korean <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_5\" name=\"q265_typeA[]\" value=\"Vietnamese\" \/>\n              <label id=\"label_input_265_5\" for=\"input_265_5\"> Vietnamese <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_265_6\" name=\"q265_typeA[]\" value=\"Other Asian\" \/>\n              <label id=\"label_input_265_6\" for=\"input_265_6\"> Other Asian <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_266\">\n        <div id=\"cid_266\" class=\"form-input-wide\">\n          <div id=\"text_266\" class=\"form-html\" data-component=\"text\">\n            <p>Native Hawaiian\/Pacific Islander (please specify)<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_267\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_267\" for=\"input_267\">  <\/label>\n        <div id=\"cid_267\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_267\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_267_0\" name=\"q267_typeA267[]\" value=\"Native Hawaiian\" \/>\n              <label id=\"label_input_267_0\" for=\"input_267_0\"> Native Hawaiian <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_267_1\" name=\"q267_typeA267[]\" value=\"Samoan\" \/>\n              <label id=\"label_input_267_1\" for=\"input_267_1\"> Samoan <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_267_2\" name=\"q267_typeA267[]\" value=\"Guamanian or Chamorro\" \/>\n              <label id=\"label_input_267_2\" for=\"input_267_2\"> Guamanian or Chamorro <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_267_3\" name=\"q267_typeA267[]\" value=\"Other Pacific Islander\" \/>\n              <label id=\"label_input_267_3\" for=\"input_267_3\"> Other Pacific Islander <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_268\">\n        <div id=\"cid_268\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_269\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_269\" for=\"input_269\"> Language <\/label>\n        <div id=\"cid_269\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_269\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_269_0\" name=\"q269_language[]\" value=\"English\" \/>\n              <label id=\"label_input_269_0\" for=\"input_269_0\"> English <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_269_1\" name=\"q269_language[]\" value=\"Spanish\" \/>\n              <label id=\"label_input_269_1\" for=\"input_269_1\"> Spanish <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox\" name=\"q269_language[other]\" id=\"other_269\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_269\" style=\"text-indent:0\" for=\"other_269\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q269_language[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_269\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_270\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_270\" for=\"input_270\">  <\/label>\n        <div id=\"cid_270\" class=\"form-input\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_270\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_270_0\" name=\"q270_input270[]\" value=\"I request language translation services.\" \/>\n              <label id=\"label_input_270_0\" for=\"input_270_0\"> I request language translation services. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_271\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_271\" for=\"input_271\"> Deaf or hard of hearing <\/label>\n        <div id=\"cid_271\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_271\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_271_0\" name=\"q271_deafOr\" value=\"Yes\" \/>\n              <label id=\"label_input_271_0\" for=\"input_271_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_271_1\" name=\"q271_deafOr\" value=\"No\" \/>\n              <label id=\"label_input_271_1\" for=\"input_271_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_272\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_272\" for=\"input_272\"> Preference <\/label>\n        <div id=\"cid_272\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_272\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_272_0\" name=\"q272_preference\" value=\"Live interpreter\" \/>\n              <label id=\"label_input_272_0\" for=\"input_272_0\"> Live interpreter <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_272_1\" name=\"q272_preference\" value=\"Video remote interpreter\" \/>\n              <label id=\"label_input_272_1\" for=\"input_272_1\"> Video remote interpreter <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_273\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_273\" for=\"input_273\"> Do you have an advanced health care directive? <\/label>\n        <div id=\"cid_273\" class=\"form-input\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_273\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_273_0\" name=\"q273_doYou273\" value=\"Yes (please bring a copy for your WWH health record)\" \/>\n              <label id=\"label_input_273_0\" for=\"input_273_0\"> Yes (please bring a copy for your WWH health record) <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_273_1\" name=\"q273_doYou273\" value=\"No\" \/>\n              <label id=\"label_input_273_1\" for=\"input_273_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_274\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_274\" for=\"input_274\"> If no, would you like more information? <\/label>\n        <div id=\"cid_274\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_274\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_274_0\" name=\"q274_ifNo\" value=\"Yes\" \/>\n              <label id=\"label_input_274_0\" for=\"input_274_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_274_1\" name=\"q274_ifNo\" value=\"No\" \/>\n              <label id=\"label_input_274_1\" for=\"input_274_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_275\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_275\" class=\"form-header\" data-component=\"header\">\n              Emergency Contact Information\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_276\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_276\" for=\"first_276\"> Name <\/label>\n        <div id=\"cid_276\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_276\" name=\"q276_name276[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_276 sublabel_276_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_276\" id=\"sublabel_276_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_276\" name=\"q276_name276[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_276 sublabel_276_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_276\" id=\"sublabel_276_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_278\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_278\" for=\"input_278\"> Relationship <\/label>\n        <div id=\"cid_278\" class=\"form-input\">\n          <input type=\"text\" id=\"input_278\" name=\"q278_relationship\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_278\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_277\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_277\" for=\"input_277_addr_line1\"> Address <\/label>\n        <div id=\"cid_277\" class=\"form-input\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_277_addr_line1\" name=\"q277_address[addr_line1]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_277 sublabel_277_addr_line1\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_277_addr_line1\" id=\"sublabel_277_addr_line1\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_277_addr_line2\" name=\"q277_address[addr_line2]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_277 sublabel_277_addr_line2\" \/>\n                  <label class=\"form-sub-label\" for=\"input_277_addr_line2\" id=\"sublabel_277_addr_line2\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-city-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_277_city\" name=\"q277_address[city]\" class=\"form-textbox form-address-city\" value=\"\" data-component=\"city\" aria-labelledby=\"label_277 sublabel_277_city\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_277_city\" id=\"sublabel_277_city\" style=\"min-height:13px\" aria-hidden=\"false\"> City <\/label>\n                <\/span>\n              <\/span>\n              <span class=\"form-address-line form-address-state-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_277_state\" name=\"q277_address[state]\" class=\"form-textbox form-address-state\" value=\"\" data-component=\"state\" aria-labelledby=\"label_277 sublabel_277_state\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_277_state\" id=\"sublabel_277_state\" style=\"min-height:13px\" aria-hidden=\"false\"> State \/ Province <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-zip-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_277_postal\" name=\"q277_address[postal]\" class=\"form-textbox form-address-postal\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_277 sublabel_277_postal\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_277_postal\" id=\"sublabel_277_postal\" style=\"min-height:13px\" aria-hidden=\"false\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_305\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_305\" for=\"input_305\"> Cell Number <\/label>\n        <div id=\"cid_305\" class=\"form-input\">\n          <input type=\"text\" id=\"input_305\" name=\"q305_cellNumber305\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_305\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_306\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_306\" for=\"input_306\"> Work Number <\/label>\n        <div id=\"cid_306\" class=\"form-input\">\n          <input type=\"text\" id=\"input_306\" name=\"q306_workNumber306\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_306\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_307\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_307\" for=\"input_307\"> Home Number <\/label>\n        <div id=\"cid_307\" class=\"form-input\">\n          <input type=\"text\" id=\"input_307\" name=\"q307_homeNumber307\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_307\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_282\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_282\" class=\"form-header\" data-component=\"header\">\n              Payment and Insurance Information\n            <\/h2>\n            <div id=\"subHeader_282\" class=\"form-subHeader\">\n              PLEASE PROVIDE YOUR INSURANCE CARD AT THE TIME OF REGISTRATION. A list of insurance we accept is available on our website. Our registration staff can also assist you.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_283\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_283\" for=\"input_283\">\n          Are you insured?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_283\" class=\"form-input jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_283\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_283_0\" name=\"q283_areYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_283_0\" for=\"input_283_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_283_1\" name=\"q283_areYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_283_1\" for=\"input_283_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_284\">\n        <div id=\"cid_284\" class=\"form-input-wide\">\n          <div id=\"text_284\" class=\"form-html\" data-component=\"text\">\n            <p style=\"text-align: left;\">If you do not have insurance, you must meet with the Public Benefits and Insurance Navigators. You may be eligible for insurance or our sliding fee schedule for your services. In order to determine your eligibility, you must provide income, family size, and residency documentation. Until we receive your documentation, you will be responsible for the full fee for your services.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_285\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_285\" class=\"form-header\" data-component=\"header\">\n              Insurances we do not accept\n            <\/h2>\n            <div id=\"subHeader_285\" class=\"form-subHeader\">\n              If we do not take your insurance OR you have an HMO, we encourage you to select a provider who takes your insurance. Choosing to get your care with us will mean being charged for the full fee of your care and seeking reimbursement from your insurer.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_286\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_286\" class=\"form-header\" data-component=\"header\">\n              Insurance Information\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_287\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_287\" for=\"input_287\"> Company <\/label>\n        <div id=\"cid_287\" class=\"form-input\">\n          <input type=\"text\" id=\"input_287\" name=\"q287_company\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_287\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_288\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_288\" for=\"input_288\"> Identification Number <\/label>\n        <div id=\"cid_288\" class=\"form-input\">\n          <input type=\"text\" id=\"input_288\" name=\"q288_identificationNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_288\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_289\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_289\" for=\"input_289\"> Group Number <\/label>\n        <div id=\"cid_289\" class=\"form-input\">\n          <input type=\"text\" id=\"input_289\" name=\"q289_groupNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_289\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_290\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_290\" for=\"input_290\"> Contact Number <\/label>\n        <div id=\"cid_290\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_290\" name=\"q290_contactNumber290\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_290 sublabel_input_290\" \/>\n            <label class=\"form-sub-label\" for=\"input_290\" id=\"sublabel_input_290\" style=\"min-height:13px\" aria-hidden=\"false\"> (on back of card) <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_342\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_342\" for=\"input_342\"> Attach Insurance ID <\/label>\n        <div id=\"cid_342\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Choose files\n              <\/div>\n              <input type=\"file\" id=\"input_342\" name=\"q342_input342[]\" multiple=\"\" class=\"form-upload-multiple\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, jpg, jpeg, png\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"2\" data-component=\"fileupload\" \/>\n              <label class=\"form-sub-label\" for=\"input_342\" style=\"min-height:13px\" aria-hidden=\"false\"> *Max 2 files, front and back (JPG, PNG, PDF) <\/label>\n            <\/span>\n            <span style=\"display:none\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_291\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_291\" for=\"input_291\"> In whose name is your insurance? <\/label>\n        <div id=\"cid_291\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_291\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_291_0\" name=\"q291_inWhose\" value=\"Self\" \/>\n              <label id=\"label_input_291_0\" for=\"input_291_0\"> Self <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_291_1\" name=\"q291_inWhose\" value=\"Other\" \/>\n              <label id=\"label_input_291_1\" for=\"input_291_1\"> Other <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_292\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_292\" for=\"input_292\"> If private\/commercial insurance <\/label>\n        <div id=\"cid_292\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_292\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_292_0\" name=\"q292_ifPrivatecommercial\" value=\"Employer-Paid\" \/>\n              <label id=\"label_input_292_0\" for=\"input_292_0\"> Employer-Paid <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_292_1\" name=\"q292_ifPrivatecommercial\" value=\"Individual-Paid\" \/>\n              <label id=\"label_input_292_1\" for=\"input_292_1\"> Individual-Paid <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <input type=\"radio\" class=\"form-radio-other form-radio\" name=\"q292_ifPrivatecommercial\" id=\"other_292\" value=\"other\" aria-label=\"Other\" \/>\n              <label id=\"label_other_292\" style=\"text-indent:0\" for=\"other_292\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q292_ifPrivatecommercial[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_292\" placeholder=\"Other\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_293\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_293\" for=\"input_293\"> Is the responsible party a Whitman-Walker patient? <\/label>\n        <div id=\"cid_293\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_293\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_293_0\" name=\"q293_isThe\" value=\"Yes\" \/>\n              <label id=\"label_input_293_0\" for=\"input_293_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_293_1\" name=\"q293_isThe\" value=\"No\" \/>\n              <label id=\"label_input_293_1\" for=\"input_293_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_294\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_294\" class=\"form-header\" data-component=\"header\">\n              Secondary Insurance Information\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_295\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_295\" for=\"input_295\"> Company <\/label>\n        <div id=\"cid_295\" class=\"form-input\">\n          <input type=\"text\" id=\"input_295\" name=\"q295_company295\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_295\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_296\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_296\" for=\"input_296\"> Identification Number <\/label>\n        <div id=\"cid_296\" class=\"form-input\">\n          <input type=\"text\" id=\"input_296\" name=\"q296_identificationNumber296\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_296\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_297\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_297\" for=\"input_297\"> Contact Number <\/label>\n        <div id=\"cid_297\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_297\" name=\"q297_contactNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_297 sublabel_input_297\" \/>\n            <label class=\"form-sub-label\" for=\"input_297\" id=\"sublabel_input_297\" style=\"min-height:13px\" aria-hidden=\"false\"> (on back of card) <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_341\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_341\" for=\"input_341\"> Attach Insurance ID <\/label>\n        <div id=\"cid_341\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Choose files\n              <\/div>\n              <input type=\"file\" id=\"input_341\" name=\"q341_attachInsurance[]\" multiple=\"\" class=\"form-upload-multiple\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, jpg, jpeg, png\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"2\" data-component=\"fileupload\" \/>\n              <label class=\"form-sub-label\" for=\"input_341\" style=\"min-height:13px\" aria-hidden=\"false\"> *Max 2 files front &amp; back (JPG, PNG, PDF) <\/label>\n            <\/span>\n            <span style=\"display:none\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_298\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_298\" class=\"form-header\" data-component=\"header\">\n              Sex\/Gender Marker with Insurance Company\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_299\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_299\" for=\"input_299\"> WWH recognizes your gender identity. For insurance billing purposes, what sex\/gender marker is on file with your insurance company? <\/label>\n        <div id=\"cid_299\" class=\"form-input\">\n          <div class=\"form-multiple-column\" data-columncount=\"4\" role=\"group\" aria-labelledby=\"label_299\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_299_0\" name=\"q299_wwhRecognizes[]\" value=\"Male\" \/>\n              <label id=\"label_input_299_0\" for=\"input_299_0\"> Male <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_299_1\" name=\"q299_wwhRecognizes[]\" value=\"Female\" \/>\n              <label id=\"label_input_299_1\" for=\"input_299_1\"> Female <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_300\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_300\" for=\"input_300\"> Is your legal name on your insurance card? <\/label>\n        <div id=\"cid_300\" class=\"form-input\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_300\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_300_0\" name=\"q300_isYour300\" value=\"Yes\" \/>\n              <label id=\"label_input_300_0\" for=\"input_300_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <input type=\"radio\" class=\"form-radio-other form-radio\" name=\"q300_isYour300\" id=\"other_300\" value=\"other\" aria-label=\"No, it\u2019s listed as\" \/>\n              <label id=\"label_other_300\" style=\"text-indent:0\" for=\"other_300\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q300_isYour300[other]\" data-otherhint=\"No, it\u2019s listed as\" size=\"15\" id=\"input_300\" placeholder=\"No, it\u2019s listed as\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_301\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_301\" for=\"input_301\">  <\/label>\n        <div id=\"cid_301\" class=\"form-input\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_301\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_301_0\" name=\"q301_input301[]\" value=\"For HIV+ patients: I understand that I may be eligible for savings on my health care if I incur a certain level of health care expenses. For more information, I will call the Public Benefits and Insurance line at 202.745.6151.\" \/>\n              <label id=\"label_input_301_0\" for=\"input_301_0\"> For HIV+ patients: I understand that I may be eligible for savings on my health care if I incur a certain level of health care expenses. For more information, I will call the Public Benefits and Insurance line at 202.745.6151. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_315\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_315\" class=\"form-header\" data-component=\"header\">\n              Acknowledgement of Responsibility for Payment for Services and Assignment of Benefits\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_316\">\n        <div id=\"cid_316\" class=\"form-input-wide\">\n          <div id=\"text_316\" class=\"form-html\" data-component=\"text\">\n            <ul>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  I understand that I am responsible for all charges and fees for my care, except any that might be covered by insurance accepted by WWH.\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  I understand that payment, including co-insurance, co-pays and self pay \/ sliding fee payments, is due at the time of service.\n                <\/span>\n              <\/li>\n              <li>\n                <span style=\"font-size: 14pt;\">\n                  For uninsured or underinsured clients: I understand that if my income, family size, or residency changes, I will bring in documentation of those changes to\u00a0\n                <\/span>\n                <span style=\"font-size: 14pt;\">\n                  the Public Benefits and Insurance Navigators. Navigators will re-assess my eligibility for insurance on the sliding fee scale and\/or grant-supported care.\n                <\/span>\n              <\/li>\n            <\/ul>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_signature\" id=\"id_356\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_356\" for=\"input_356\">\n          Signature\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_356\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_356\" class=\"signature-pad-wrapper\" style=\"width:352px;height:152px\">\n              <div data-wrapper-react=\"true\">\n                <!--[if IE 7]>\n                  <script type=\"text\/javascript\" src=\"\/js\/vendor\/json2.js\"><\/script>\n                <![endif]-->\n              <\/div>\n              <div class=\"signature-line signature-wrapper signature-placeholder\" data-component=\"signature\" style=\"width:352px;height:152px\">\n                <div id=\"sig_pad_356\" data-width=\"350\" data-height=\"150\" data-id=\"356\" data-required=\"true\" class=\"pad validate[required]\">\n                <\/div>\n                <input type=\"hidden\" name=\"q356_signature356\" class=\"output4\" id=\"input_356\" \/>\n              <\/div>\n              <span class=\"clear-pad-btn clear-pad\" role=\"button\" tabindex=\"0\">\n                Clear\n              <\/span>\n            <\/div>\n            <div data-wrapper-react=\"true\">\n              <script type=\"text\/javascript\">\n              window.signatureForm = true\n              <\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_319\">\n        <div id=\"cid_319\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:0px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_317\">\n        <div id=\"cid_317\" class=\"form-input-wide\">\n          <div id=\"text_317\" class=\"form-html\" data-component=\"text\">\n            <span style=\"font-size: 24pt;\">\n              Consents and Acknowledgements\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_320\">\n        <div id=\"cid_320\" class=\"form-input-wide\">\n          <div id=\"text_320\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 14pt;\">In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we\u00a0<\/span><span style=\"font-size: 14pt;\">have provided you with certain important information and documents. If you have any questions about any of this information or\u00a0<\/span><span style=\"font-size: 14pt;\">need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable\u00a0<\/span><span style=\"font-size: 14pt;\">with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask\u00a0<\/span><span style=\"font-size: 14pt;\">questions, and are giving your consent.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">GENERAL CONSENT TO TREAT<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I voluntarily agree to receive services from WWH, and authorize the providers of WWH to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. Finally, I know that WWH sometimes has students\/residents being trained as doctors, nurses, therapists and other health care providers who might be helping to care for me. These individuals are under the supervision of licensed providers. I understand that WWH is committed to involving me in my care and that no one can be given care at WWH without agreeing to the care unless there is an emergency. If there is an emergency, I know that someone at WWH may help me without waiting for me to say okay. I understand that some services require me to sign another Informed Consent to Treatment so I may be asked to complete that later.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">NOTICE OF PRIVACY PRACTICE<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I have been given a copy of WWH\u2019s Notice of Privacy Practices and I understand that WWH is required by law to protect my personal health information. I have had the chance to ask questions about WWH\u2019s Notice of Privacy Practices and feel comfortable with the protections that it offers me. I understand that there are times when the law allows my personal health information to be shared with individuals or entities outside of WWH, including but not limited to for treatment, payment and operations purposes, when required by law, and in connection with the mandatory reporting of certain diseases.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">INTEGRATED MODEL OF CARE<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">WWH offers a wide variety of services to its clients. I understand that in order for me to get the best service for my needs, programs within WWH may share information concerning my health to ensure the quality and continuity of my care across service areas. For example, WWH may share my demographic information, medical and other service referrals, and other non-clinical information with WWH Legal Services to allow for legal referrals and for scheduling purposes. The details of my health records will only be shared with WWH lawyers if I agree for them to take my legal case.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">HEALTH INFORMATION EXCHANGE AND PDMP<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I understand that WWH participates in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange (HIE) and the Capital Partners in Care (CPC) HIE. These HIEs provide a way of sharing my health information among participating doctors\u2019 offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. I have been informed that my health information, including information relating to the mental health services I receive at WWH, will be shared with the HIEs in order to better coordinate my care and assist providers and public health officials in making more informed decisions. I have been advised by WWH that I have the right to \u201copt-out\u201d of the HIEs at any time. I understand that I can request a copy of WWH\u2019s \u201copt-out\u201d form and direct WWH to disable access to my health information, except to the extent that disclosure of such information is permitted or mandated by law. <\/span><\/p>\n            <p><span style=\"font-size: 14pt;\">I also acknowledge that it may be necessary for my Whitman-Walker Health provider to obtain information about my medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">Patient Rights and Responsibilities<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I have been given a copy of the WWH Rights and Responsibilities document and understand that both WWH and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint or grievance with WWH, as described on the WWH website and in the Patient Feedback notice posted on bulletin boards at the health center. I also understand that WWH has a Patient Handbook that contains information about being a patient at WWH including services offered, hours of operation and contact information.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">RELEASE OF INFORMATION FOR BILLING AND CONSENT TO REIMBURSE<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I know that WWH needs to send parts of my personal health information to organizations that help pay for my care, such as my insurance company or an organization that grants money to WWH. I allow WWH to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act (HIPAA).<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">CONSENT TO COMMUNICATIONS VIA E-COMMUNICATIONS<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">The U. S. Department of Health and Human Services permits patients to request electronic communications with their providers. I acknowledge that the most secure means of communicating with WWH is by use of the patient portal. Any other method of communicating electronically presents a greater risk of breach of privacy because the communications may be intercepted by third parties or transmitted to unintended parties. WWH will make an effort to limit the information it includes in e-communications with me. I understand, however, that information about my medical care (including appointments, billing information, prescriptions and test results) may be sent to me electronically. By signing below, I am choosing and consenting freely to electronic communications. If I wish to discontinue e-communications with WWH, I can submit an E-communications Opt-Out Form available from Client Services or on the WWH website.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">ACKNOWLEDGMENT OF DUTY TO REIMBURSE WWH FOR HEALTH CARE SERVICES<\/span><\/strong><\/p>\n            <p><span style=\"font-size: 14pt;\">I understand that WWH offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay based on their level of income. In order to be eligible for WWH\u2019s Sliding Fee Scale of discounted or free services, I will need to provide WWH\u2019s Public Benefits and Insurance Navigation team with documents establishing that I meet income eligibility requirements. If I do not provide the required documents to WWH, I am responsible for paying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service. I also understand that if I am an insured patient with insurance WWH does not accept, or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong><span style=\"font-size: 14pt;\">By signing my name below, I am acknowledging that I have read, and fully understand, each of the separate paragraphs set forth above.<\/span><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_signature\" id=\"id_357\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_357\" for=\"input_357\">\n          Signature\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_357\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_357\" class=\"signature-pad-wrapper\" style=\"width:352px;height:152px\">\n              <div data-wrapper-react=\"true\">\n                <!--[if IE 7]>\n                  <script type=\"text\/javascript\" src=\"\/js\/vendor\/json2.js\"><\/script>\n                <![endif]-->\n              <\/div>\n              <div class=\"signature-line signature-wrapper signature-placeholder\" data-component=\"signature\" style=\"width:352px;height:152px\">\n                <div id=\"sig_pad_357\" data-width=\"350\" data-height=\"150\" data-id=\"357\" data-required=\"true\" class=\"pad validate[required]\">\n                <\/div>\n                <input type=\"hidden\" name=\"q357_signature\" class=\"output4\" id=\"input_357\" \/>\n              <\/div>\n              <span class=\"clear-pad-btn clear-pad\" role=\"button\" tabindex=\"0\">\n                Clear\n              <\/span>\n            <\/div>\n            <div data-wrapper-react=\"true\">\n              <script type=\"text\/javascript\">\n              window.signatureForm = true\n              <\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_337\">\n        <div id=\"cid_337\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_323\">\n        <div id=\"cid_323\" class=\"form-input-wide\">\n          <div id=\"text_323\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 24pt;\"><strong>Patient Acknowledgement of Financial Obligation<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_325\">\n        <div id=\"cid_325\" class=\"form-input-wide\">\n          <div id=\"text_325\" class=\"form-html\" data-component=\"text\">\n            <p><strong>PREAMBLE<\/strong><\/p>\n            <p>Whitman-Walker Health (\u201cWWH\u201d) is a Federally Qualified Health Center (\u201cFQHC\u201d or \u201cHealth Center\u201d) that is subject to Section 330 of the Public Health Service Act. Section 330 specifies that Health Centers must assure that no patient will be denied services due to their inability to pay for such services. It also requires Health Centers to adopt written policies and procedures to maximize collections and reimbursement for their costs in providing health services.<\/p>\n            <p>\u00a0\u00a0<\/p>\n            <p><strong>I UNDERSTAND THAT I AM RESPONSIBLE FOR:<\/strong><\/p>\n            <ul>\n              <li>\n                Contributing to the cost of my care and treatment as my health insurance coverage requires and based on my ability to pay;\n              <\/li>\n              <li>\n                Providing WWH with the information it needs to receive reimbursement for the treatment or services it provides to me;\n              <\/li>\n              <li>\n                Requesting consideration for discounted fees under WWH\u2019s Sliding Fee Scale based on my level of income, and providing documentation to support eligibility for discounted fees that may be requested by WWH\u2019s Public Benefits and Insurance Navigation team;\n              <\/li>\n              <li>\n                Assisting the Public Benefits and Insurance Navigators with any application for insurance or public benefits that I may be entitled to;\n              <\/li>\n              <li>\n                Paying my co-payment (if applicable) when I check-in for my appointment and paying my deductible or any other fees that may be owed at the conclusion of the medical visit;\n              <\/li>\n              <li>\n                Paying my fees for medical, behavioral health, or dental services received at WWH in full at the time of service, either upon check-in or at check-out as requested by WWH if I have been deemed a self-pay patient based on the fact that I have insurance coverage that WWH does not accept but have elected to remain in care at WWH.\n              <\/li>\n            <\/ul>\n            <p>I understand that if I am an insured self-pay patient or an insured patient with a copay obligation who fails to pay fees or copays due at the time of service, I will not be scheduled for future appointments until such time as my outstanding fees or copays are paid. If I fail to pay my outstanding fees or copays in 30 days, WWH presumes that you are transitioning your care to another provider. If you have a health care issue requiring immediate care during the next 30 days, you may contact WWH and your provider will determine whether you should be seen. To prevent you from running out of medications, a thirty (30) day renewal will be made available if needed.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_signature\" id=\"id_358\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_358\" for=\"input_358\">\n          Signature\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_358\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_358\" class=\"signature-pad-wrapper\" style=\"width:352px;height:152px\">\n              <div data-wrapper-react=\"true\">\n                <!--[if IE 7]>\n                  <script type=\"text\/javascript\" src=\"\/js\/vendor\/json2.js\"><\/script>\n                <![endif]-->\n              <\/div>\n              <div class=\"signature-line signature-wrapper signature-placeholder\" data-component=\"signature\" style=\"width:352px;height:152px\">\n                <div id=\"sig_pad_358\" data-width=\"350\" data-height=\"150\" data-id=\"358\" data-required=\"true\" class=\"pad validate[required]\">\n                <\/div>\n                <input type=\"hidden\" name=\"q358_signature358\" class=\"output4\" id=\"input_358\" \/>\n              <\/div>\n              <span class=\"clear-pad-btn clear-pad\" role=\"button\" tabindex=\"0\">\n                Clear\n              <\/span>\n            <\/div>\n            <div data-wrapper-react=\"true\">\n              <script type=\"text\/javascript\">\n              window.signatureForm = true\n              <\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_318\">\n        <div id=\"cid_318\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:0px;margin-bottom:0px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_329\">\n        <div id=\"cid_329\" class=\"form-input-wide\">\n          <div id=\"text_329\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 24pt;\"><strong>Patient Rights and Responsibilities Statement<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_328\">\n        <div id=\"cid_328\" class=\"form-input-wide\">\n          <div id=\"text_328\" class=\"form-html\" data-component=\"text\">\n            <div class=\"tbl-first-td cls-rights\">\n              <p><strong>AS A WWH PATIENT, YOU HAVE THE RIGHT TO:<\/strong><\/p>\n              <p><strong>ACCESS SERVICES in a safe and respectful manner<\/strong><\/p>\n              <ul>\n                <li>\n                  Receive services at WWH regardless of your race, color, religion, sex, marital status, sexual orientation, gender identity or expression, English language proficiency, national origin, age, disability, veteran status, or any other status protected by law.\n                <\/li>\n              <\/ul>\n              <ul>\n                <li>\n                  <p>Receive respect and consideration from every employee, volunteer or trainee you interact with at WWH.<\/p>\n                <\/li>\n                <li>\n                  <p>Feel safe from harm and free from verbal, physical, or psychological abuse, intimidation or harassment when you are at WWH\u2019s facilities.<\/p>\n                <\/li>\n              <\/ul>\n              <p><strong>PRIVACY regarding your personal health information<\/strong><\/p>\n              <ul>\n                <li>\n                  <p>Expect WWH to comply with the Federal and State privacy laws when using or disclosing information about you or the health care and related services you receive at WWH.<\/p>\n                <\/li>\n                <li>\n                  <p>Receive a copy of WWH\u2019s Notice of Privacy Practices when you register as a new patient so that you will be more fully informed about your privacy rights.<\/p>\n                <\/li>\n                <li>\n                  <p>Active involvement in your ongoing care<\/p>\n                <\/li>\n                <li>\n                  <p>Help WWH providers and staff to develop a plan for the treatment and services you receive at WWH.<\/p>\n                <\/li>\n                <li>\n                  <p>Provide (or withhold) your consent to voluntary treatment, including your participation in clinical research, and be informed about the consequences of refusing any treatment or service.<\/p>\n                <\/li>\n                <li>\n                  <p>Provide WWH staff members with positive or negative feedback about your care, or voice your concerns or complaints about the Health Center.<\/p>\n                <\/li>\n              <\/ul>\n              <strong>TIMELY INFORMATION about your care<\/strong>\n              <br \/>\n              <ul>\n                <li>\n                  <p>Receive complete information about your diagnosis, and treatment or service plan in plain language that you can understand.<\/p>\n                <\/li>\n                <li>\n                  <p>Obtain a copy of your medical records upon request unless the law permits WWH to withhold the records.<\/p>\n                <\/li>\n                <li>\n                  <p>Receive an explanation of the costs associated with your care at WWH.<\/p>\n                <\/li>\n                <li>\n                  <p>Obtain assistance with referrals to other providers.<\/p>\n                <\/li>\n              <\/ul>\n              <strong>QUALITY SERVICES from our health center<\/strong>\n              <br \/>\n              <ul>\n                <li>\n                  <p>Receive coordinated health care treatment and services consistent with professional standards.<\/p>\n                <\/li>\n                <li>\n                  <p>Receive services from licensed and credentialed WWH providers.<\/p>\n                <\/li>\n                <li>\n                  <p>Request WWH to provide hearing, language, literacy or other communication assistance required by law.<\/p>\n                <\/li>\n                <li>\n                  <p>Receive services and care in the least restrictive environment feasible, free from chemical or physical restraints.<\/p>\n                <\/li>\n              <\/ul>\n            <\/div>\n            <div class=\"tbl-nxt-td cls-rights\" style=\"text-align: left; vertical-align: top;\">\n              <p><strong>AS A WWH PATIENT, YOU ARE RESPONSIBLE FOR:<\/strong><\/p>\n              <p><strong>YOUR PERSONAL INTERACTIONS with our health center team<\/strong><\/p>\n              <ul>\n                <li>\n                  Treat WWH employees, volunteers, trainees, contractors, other patients, and guests with respect at all times.\n                <\/li>\n                <li>\n                  Do not make any threatening or offensive statements at WWH\u2019s facilities.\n                <\/li>\n                <li>\n                  Do not engage in any act of physical violence or other threatening or inappropriate behavior at WWH\u2019s facilities, which includes bringing a weapon of any kind on site.\n                <\/li>\n                <li>\n                  Do not distribute or use alcohol or drugs on WWH\u2019s property or enter a WWH facility or program under the influence of illegal drugs or alcohol.\n                <\/li>\n              <\/ul>\n              <p><strong>ACTIVE ENGAGEMENT in your care<\/strong><\/p>\n              <ul>\n                <li>\n                  Take an active part in your treatment or service plan at WWH and stay in contact with your providers about your care.\n                <\/li>\n                <li>\n                  Request any hearing, language, literacy or other communications assistance you may need at least 48 hours prior to your visit.\n                <\/li>\n                <li>\n                  Show up for your appointments at least 15 minutes ahead of schedule and provide advance notice whenever it becomes necessary to cancel an appointment at WWH.\n                <\/li>\n                <li>\n                  Contribute to the cost of your care that the law or the health plan that you participate in require you to pay.\n                <\/li>\n              <\/ul>\n              <p><strong>TIMELY INFORMATION sharing<\/strong><\/p>\n              <ul>\n                <li>\n                  <p>Provide WWH with complete, accurate, and truthful information at all times.<\/p>\n                  <p>WWH\u2019s Patient Rights and Responsibilities Policy grants WWH discretion to take action placing limits on a patient\u2019s ability to receive treatment or services at WWH based on a patient\u2019s failure to meet their Responsibilities or for any other reason permitted by law. Likewise, any WWH patient has discretion to decide not to seek further treatment or services at WWH based on WWH\u2019s failure to abide by the patient Rights set forth in this Statement or for any other reason.<\/p>\n                <\/li>\n              <\/ul>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_331\">\n        <div id=\"cid_331\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_333\">\n        <div id=\"cid_333\" class=\"form-input-wide\">\n          <div id=\"text_333\" class=\"form-html\" data-component=\"text\">\n            <p><strong><span style=\"font-size: 24pt;\">Notice of Privacy Practices<\/span><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_334\">\n        <div id=\"cid_334\" class=\"form-input-wide\">\n          <div id=\"text_334\" class=\"form-html\" data-component=\"text\">\n            <div class=\"tbl-first-td cls-rights\" style=\"text-align: left; vertical-align: top;\">\n              <p><strong>This Notice describes how medical information about you may\u00a0<\/strong><strong>be used and disclosed by Whitman-Walker Health (WWH) and\u00a0<\/strong><strong>how you can get access to this information. Please review it\u00a0<\/strong><strong>carefully.<\/strong><\/p>\n              <p><strong>YOUR RIGHTS<\/strong><\/p>\n              <p>You have the right to:<\/p>\n              <ul>\n                <li>\n                  Get a copy of your paper or electronic medical record\n                <\/li>\n                <li>\n                  Correct your paper or electronic medical record\n                <\/li>\n                <li>\n                  Request confidential communications\n                <\/li>\n                <li>\n                  Ask us to limit the information about you that we share\n                <\/li>\n                <li>\n                  Get a list of those with whom we\u2019ve shared your information\n                <\/li>\n                <li>\n                  Get a copy of this Notice of Privacy Practices\n                <\/li>\n                <li>\n                  Choose someone to act as your personal representative for purposes of your health information\n                <\/li>\n                <li>\n                  File a complaint if you believe your privacy rights have been violated\n                <\/li>\n              <\/ul>\n              <p><strong>YOUR CHOICES<\/strong><\/p>\n              <p>You have some choices in the way that we use and share information as we:<\/p>\n              <ul>\n                <li>\n                  Tell family and friends about your health\n                <\/li>\n                <li>\n                  Provide disaster relief\n                <\/li>\n                <li>\n                  Provide mental health care\n                <\/li>\n                <li>\n                  Market our services and sell your information\n                <\/li>\n                <li>\n                  Raise funds\n                <\/li>\n              <\/ul>\n              <p><strong>OUR USES AND DISCLOSURES<\/strong><\/p>\n              <p>We may use and share your information as we:<\/p>\n              <ul>\n                <li>\n                  Treat you\n                <\/li>\n                <li>\n                  Run our organization\n                <\/li>\n                <li>\n                  Bill for your services\n                <\/li>\n                <li>\n                  Help with public health and safety issues\n                <\/li>\n                <li>\n                  Do research\n                <\/li>\n                <li>\n                  Comply with the law\n                <\/li>\n                <li>\n                  Respond to organ and tissue donation requests\n                <\/li>\n                <li>\n                  Work with a medical examiner or funeral director\n                <\/li>\n                <li>\n                  Address workers\u2019 compensation, law enforcement, and other government requests\n                <\/li>\n                <li>\n                  Respond to lawsuits and legal actions\n                <\/li>\n              <\/ul>\n              <p><em>A more detailed description of your rights, your choices and our uses and disclosures of your health information is set forth below:<\/em><\/p>\n              <p>\u00a0<\/p>\n              <p><strong>YOUR RIGHTS<\/strong><\/p>\n              <p>When it comes to your health information, you have certain rights. This section of our Notice of Privacy Practices explains your rights and some of our responsibilities under the law.<\/p>\n              <p><strong>Get an electronic or paper copy of your medical record.<\/strong><\/p>\n              <ul>\n                <li>\n                  You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.\n                <\/li>\n                <li>\n                  We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.\n                <\/li>\n                <li>\n                  You can ask us to correct health information about you that you think is incorrect or incomplete.\n                <\/li>\n              <\/ul>\n              <p><strong>Ask us to amend your medical record<\/strong><\/p>\n              <p>We may say \u201cno,\u201d but we\u2019ll tell you why in writing within 60 days In these cases we generally do not share your information unless you give us written permission:<\/p>\n              <ul>\n                <li>\n                  Marketing purposes\n                <\/li>\n                <li>\n                  Sale of your information\n                <\/li>\n                <li>\n                  Most sharing of psychotherapy notes\n                <\/li>\n              <\/ul>\n              <p><strong>In the case of fundraising:<\/strong><\/p>\n              <ul>\n                <li>\n                  We may contact you for fundraising efforts, but you can tell us not to contact you again.\n                <\/li>\n              <\/ul>\n              <p><strong>OUR USES AND DISCLOSURES OF INFORMATION ABOUT YOU<\/strong><\/p>\n              <p><strong>How do we typically use or share your health information?<\/strong><\/p>\n              <p>We typically use or share your health information in the following ways.<\/p>\n              <p><strong>To treat you<\/strong><\/p>\n              <p>We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.<\/p>\n              <p><strong>To run our organization<\/strong><\/p>\n              <p>We can use and share your health information to run our health center, improve your care, and contact you when necessary. Example: We use health information about you to improve the quality of care we provide to you and others.<\/p>\n              <p><strong>In order to bill for your services<\/strong><\/p>\n              <p>We can use and share your health information to bill and get payment from health plans or other entities. Example: We can give information about you to your health<\/p>\n              <p>insurance plan in order to be paid for the services you receive at the health center.<\/p>\n              <p><strong>HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?<\/strong><\/p>\n              <p>We are allowed or required to share your information in other ways\u2014usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. If you want to learn more you can go to: www.hhs.gov\/ocr\/privacy\/hipaa\/understanding\/consumers\/index.html<\/p>\n              <p><strong>Help with public health and safety issues<\/strong><\/p>\n              <p>We can share health information about you for certain situations such as:<\/p>\n              <ul>\n                <li>\n                  Preventing disease\n                <\/li>\n                <li>\n                  Helping with product recalls\n                <\/li>\n                <li>\n                  Reporting adverse reactions to medications\n                <\/li>\n                <li>\n                  Reporting suspected abuse, neglect, or domestic violence\n                <\/li>\n                <li>\n                  Preventing or reducing a serious threat to anyone\u2019s health or safety\n                <\/li>\n              <\/ul>\n              <p>\u00a0<\/p>\n              <p><span style=\"font-size: 12pt;\"><strong>Request confidential communications<\/strong><\/span><\/p>\n              <p>Make a reasonable request to contact you in a specific way (for example, home or office phone) or to send mail to a different address.<br \/>Ask us to limit what we use or share<\/p>\n              <p>You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say \u201cno\u201d if it would affect your care.<br \/>If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say \u201cyes\u201d unless a law requires us to share that information.<br \/>\u00a0<\/p>\n            <\/div>\n            <div class=\"tbl-nxt-td cls-rights\" style=\"text-align: left; vertical-align: top;\">\n              <p><strong>Do research<\/strong><\/p>\n              <p>We can use or share your information for health research.<\/p>\n              <p><strong>Comply with the law<\/strong><\/p>\n              <p>We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we\u2019re complying with federal privacy la<\/p>\n              <p><strong>Get a list of those with whom we\u2019ve shared information<\/strong><\/p>\n              <ul>\n                <li>\n                  You can ask for a list (accounting) of the times we\u2019ve shared your health information for six years prior to the date you ask, who we shared it with, and why.\n                <\/li>\n                <li>\n                  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We\u2019ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.\n                <\/li>\n              <\/ul>\n              <p><strong>Get a copy of this Notice of Privacy Practices<\/strong><\/p>\n              <ul>\n                <li>\n                  You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically and we will provide you with a paper copy promptly.\n                <\/li>\n              <\/ul>\n              <p><strong>Choose someone to act for you<\/strong><\/p>\n              <ul>\n                <li>\n                  If you have given someone health care power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.\n                <\/li>\n                <li>\n                  Our Legal Services Department can assist you with the preparation of a health care power of attorney document that provides authority for another person to act on your behalf.\n                <\/li>\n              <\/ul>\n              <p><strong>File a complaint if you feel your rights are violated<\/strong><\/p>\n              <ul>\n                <li>\n                  You can complain if you feel we have violated your rights by contacting Whitman-Walker\u2019s Privacy Officer at 202.939.7694.\n                <\/li>\n                <li>\n                  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington, DC 20201, calling 1.877. 696.6775, or visiting www.hhs.gov\/ocr\/privacy\/hipaa\/complaints.\n                <\/li>\n                <li>\n                  We will not retaliate against you for filing a complaint.\n                <\/li>\n              <\/ul>\n              <p><strong>YOUR CHOICES<\/strong><\/p>\n              <p>For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:<\/p>\n              <ul>\n                <li>\n                  Share information with your family, close friends, or others involved in your care\n                <\/li>\n                <li>\n                  Share information in a disaster relief situation\n                <\/li>\n              <\/ul>\n              <p>If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.<\/p>\n              <p><strong>Respond to organ and tissue donation requests<\/strong><\/p>\n              <p>We can share health information about you with organ procurement organizations.<\/p>\n              <p><strong>Work with a medical examiner or funeral director<\/strong><\/p>\n              <p>We can share health information about a deceased patient with a coroner, medical examiner, or funeral director.<\/p>\n              <p><strong>Address workers\u2019 compensation, law enforcement, and other\u00a0government requests.<\/strong><\/p>\n              <p>We can use or share health information about you:<\/p>\n              <ul>\n                <li>\n                  For workers\u2019 compensation claims\n                <\/li>\n                <li>\n                  For law enforcement purposes or with a law enforcement official\n                <\/li>\n                <li>\n                  With health oversight agencies for activities authorized by law\n                <\/li>\n                <li>\n                  For special government functions such as military, national security, and presidential protective services\n                <\/li>\n              <\/ul>\n              <p><strong>Respond to lawsuits and legal actions<\/strong><\/p>\n              <p>We can share health information about you in response to a court or administrative order, or in response to a subpoena.<\/p>\n              <p><strong>OUR RESPONSIBILITIES<\/strong><\/p>\n              <ul>\n                <li>\n                  We are required by law to maintain the privacy and security of your protected health information.\n                <\/li>\n                <li>\n                  We will let you know in writing if a breach occurs that may have compromised the privacy or security of your information.\n                <\/li>\n                <li>\n                  We must follow the duties and privacy practices described in this Notice and give you a copy of it.\n                <\/li>\n                <li>\n                  We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.\n                <\/li>\n                <li>\n                  We do not share records relating to your participation in a WWH substance abuse program or your mental health records with providers outside of WWH without your written authorization.\n                <\/li>\n              <\/ul>\n              <p>The original effective date of this Notice is April 14, 2003 and the Notice was most recently updated on September 24, 2019. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice of Privacy Practices will be available upon request, in our office, and on our web site.<\/p>\n              <p>WWH is participating in the Chesapeake Regional Information System for Our Patients (CRISP) Health Information Exchange and the Capital Partners in Care (CPC) Health Information Exchange. These health information exchanges (HIEs) provide a way of sharing your health information among participating doctors\u2019 offices, hospitals, labs, radiology centers, and other providers through secure, electronic means. As permitted by DC Mental Health Information Amendment Act of 2018, your mental health information will be shared with the CPC and CRISP HIEs to provide faster access, better coordination of care, and improved knowledge for providers. If you do not want your mental health information to be shared among your providers, you have the right to opt-out of the HIEs at any time by completing an Opt-Out Form available at the Front Desk. Note, however, that it is not possible to share some but not all of your health and mental health information. If you opt-out of one or both HIEs, none of your health information will be shared with that HIE for purposes of coordinating your care and treatment. It may also necessary for your Whitman-Walker Health provider to obtain information about your medications through the Prescription Drug Monitoring Program (PDMP) as required by state law.<\/p>\n              <p><strong>Acknowledgement of receipt of this Notice of Privacy Practices is indicated by your signature on our Informed Consent Form that is scanned into your electronic medical record.<\/strong><\/p>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_338\">\n        <div id=\"cid_338\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_339\">\n        <div id=\"cid_339\" class=\"form-input-wide\">\n          <div id=\"text_339\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size: 24pt;\"><strong>Telehealth<\/strong><\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><strong>CONSENT TO RECEIVE MEDICAL, DENTAL AND BEHAVIORAL HEALTH SERVICES VIA TELEHEALTH<\/strong><\/p>\n            <p>This form gives you facts about, and risks of, telehealth services.<\/p>\n            <p>By signing this form, or verbally agreeing to its terms, you consent to receive telehealth services and treatment by a Whitman-Walker Health medical, dental or behavioral health provider, and you acknowledge your understanding and agreement to the following:<\/p>\n            <ul>\n              <li>\n                You will be participating in a medical, dental or behavioral health telehealth visit at a location different from where your Whitman-Walker Health provider is located, which may limit the ability of your provider to provide medical care. For example, your provider will not be able to conduct an in-person physical examination and cannot provide emergency medical services during a telehealth visit.\n              <\/li>\n              <li>\n                It is the role of your provider to determine whether or not the condition you are being diagnosed with or treated for is appropriate for a telehealth visit.\n              <\/li>\n              <li>\n                You or your provider may require an in-person examination before or after diagnosing or prescribing a treatment plan.\n              <\/li>\n              <li>\n                If you are experiencing a medical or mental health emergency, you understand you will be asked to immediately call 911 or go to the nearest emergency room.\n              <\/li>\n              <li>\n                This telehealth visit and future telehealth visits will be conducted with the use of real-time interactive two-way audio, video or other electronic communications. Whitman-Walker Health has taken steps to protect the security of information disclosed during the session, but Internet security and privacy are not guaranteed. You understand that (1) security protocols could fail, potentially causing a breach of your protected health information, (2) information you transmit through telehealth technology may be insufficient to allow for appropriate medical decision-making by your provider (for example, poor image resolution); or (3) failures of equipment (for example, servers, devices) or infrastructure (for example, communications lines, power supply) may cause delays in medical evaluation and treatment, or loss of information, and you agree to hold Whitman-Walker Health harmless for any loss of protected health information that occurs due to technological failure.\n              <\/li>\n              <li>\n                Whitman-Walker Health will need to obtain an accurate medical and mental health history, condition(s) and description of current or previous medical or mental health care from you during telehealth sessions to best support diagnosis, therapy, follow-up and\/or education.\n              <\/li>\n              <li>\n                Your provider may have other medical staff participate in your telehealth visit and you agree to medical staff participation. You have the right, at any time, to request the medical staff to leave the telehealth visit.\n              <\/li>\n              <li>\n                If you allow another person to participate in your telehealth visit (e.g., family, caregiver), you consent to their participation.\n              <\/li>\n              <li>\n                Whitman-Walker Health may share your identifiable information from your telehealth visits with third parties, except as prohibited by law. Whitman-Walker Health may separately request your consent to share identifiable information from your telehealth visits with third parties, as necessary.\n              <\/li>\n              <li>\n                There are potential risks to telehealth, such as technological interruptions, unauthorized access, and technical difficulties. Your provider will obtain or confirm your contact information in order to reach you in the event of a technical issue.\n              <\/li>\n              <li>\n                You or your provider can stop any telehealth visit if either of you feel that the videoconferencing connections are not adequate for the situation.\n              <\/li>\n              <li>\n                Having a telehealth visit is your choice. Even if you have agreed to the session, you can change your mind about participating in this or future telehealth sessions. You have the right to withdraw your consent.\n              <\/li>\n            <\/ul>\n            <p><strong>BY SIGNING YOUR NAME BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ (OR HAVE HAD READ TO YOU), AND UNDERSTAND EACH OF THE SEPARATE PARAGRAPHS ABOVE, YOU HAVE HAD A CHANCE TO ASK WHITMAN-WALKER HEALTH STAFF ANY QUESTIONS YOU MAY HAVE, AND YOU CONSENT TO THE TELEHEALTH SERVICES AND TREATMENT PROVIDED TO YOU BY WHITMAN-WALKER HEALTH.<\/strong><\/p>\n            <p><strong>This Consent lasts for as long as telehealth services continue, unless you exercise your right to withdraw your consent at any time.<\/strong><\/p>\n            <p><strong>If you are not able to place a wet signature or electronic signature on this Consent and return it to Whitman-Walker Health, you will verbally inform Whitman-Walker Health that you have reviewed this form and provide your verbal consent. Whitman-Walker Health will document your consent to telehealth services in your electronic medical record.<\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_344\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_344\" for=\"input_344\">\n          Name of Patient:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_344\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_344\" name=\"q344_nameOf\" data-type=\"input-textbox\" class=\"form-textbox validate[required, Fill Mask]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_344\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_346\">\n        <label class=\"form-label form-label-left form-label-auto\" 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