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104.76.102.49  Public Scan

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Submitted URL: https://www.caremark.com/wps/portal/GUEST_DIGITAL_DOC_VIEW?XID=KXJ9BbYY&cid=264&oneClick=eob
Effective URL: https://www.caremark.com/fast/eob/
Submission: On March 31 via manual from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: generic — 

<form novalidate="" id="generic" name="generic" autocomplete="off" class="ng-untouched ng-pristine ng-invalid">
  <div class="main-content-wrapper1">
    <div class="form-group">
      <div class="row">
        <div class="col-12 col-sm-6"><label for="vUserDob" id="vUserDobLabel">Birth date</label><input id="vUserDob" type="tel" aria-labelledby="vUserDobLabel vUserDobHint" formcontrolname="dateOfBirth" autocomplete="bday"
            class="ng-untouched ng-pristine ng-invalid">
          <div id="vUserDobHint" class="help-text"><strong>MMDDYYYY</strong></div><!---->
        </div>
      </div>
    </div>
    <div class="form-group">
      <div class="row">
        <div class="col-12 col-sm-6"><label for="vUserZipCode" id="vUserZipCodeLabel">ZIP code</label><input id="vUserZipCode" type="text" aria-labelledby="vUserZipCodeLabel vUserZipCodeHint" formcontrolname="zipCode" maxlength="5"
            autocomplete="postal-code" cvsnumericonly="" class="ng-untouched ng-pristine ng-invalid">
          <div id="vUserZipCodeHint" class="help-text"><strong>Enter 5-digit ZIP code</strong></div><!---->
        </div>
      </div>
    </div>
    <div class="form-group">
      <div class="row">
        <div class="col-12 col-sm-3"><br><button type="submit" class="btn cvs-primary-btn btn-lg btn-block btn-control">Confirm your information</button></div>
      </div>
    </div>
  </div>
</form>

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