adapthealthnc.hmebillpay.com Open in urlscan Pro
204.193.153.122  Public Scan

Form analysis
1 forms found in the DOM

POST /Payments/GuestPatientPay/Payment

<form action="/Payments/GuestPatientPay/Payment" id="formGuestPatientPayment" method="post" novalidate="novalidate"><input name="__RequestVerificationToken" type="hidden"
    value="qPKgJCNEHf9cuCxtqxJLwVj1UPyYHhFBEvNuXFVwGMpBFdG-3jbhnj528DiCRugoEcQ8Fb_B92Uy0kTzhxwoeblQFWNRPvcSn0ABdvJ23441"><input id="HdnIsEmailInvalid" name="HdnIsEmailInvalid" type="hidden" value=""><input id="HdnEmailVerdict" name="HdnEmailVerdict"
    type="hidden" value="">
  <div class="bg-primary p-30">
    <h2><strong>Patient Information </strong></h2>
    <em class="required-message font-12">All fields are required</em>
    <div class="row m-t-20">
      <div class="col-md-6">
        <div id="divDOB" class="form-group">
          <label for="DOB" class="width-100">
            <span> Date of birth </span>
          </label>
          <span class="error-text hidden"><span class="field-validation-valid" data-valmsg-for="DOB" data-valmsg-replace="false">Date of birth field is required</span> </span>
          <span class="k-widget k-datepicker form-control" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" class="form-control k-input" data-val="true" data-val-date="The field Date of birth must be a date." id="DOB"
                name="DOB" oncopy="return false;" oncut="return false;" ondrag="return false;" ondrop="return false;" onblur="return validateDOB();" onkeypress="return NumbersOnly(event)" onkeyup="return FormatDate(event,this);"
                onpaste="return false;" onselectstart="return false;" type="text" data-role="datepicker" role="combobox" aria-expanded="false" aria-haspopup="grid" aria-owns="DOB_dateview" aria-disabled="false" aria-readonly="false"
                required="required" style="width: 100%;"><span unselectable="on" class="k-select" aria-label="select" role="button" aria-controls="DOB_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
          <script>
            kendo.syncReady(function() {
              jQuery("#DOB").kendoDatePicker({
                "format": "MM/dd/yyyy",
                "min": new Date(1900, 0, 1, 0, 0, 0, 0),
                "max": new Date(2024, 8, 24, 0, 0, 0, 0)
              });
            });
          </script>
          <p class="opacity-60 m-t-10"><small><i>(Format: MM/DD/YYYY)</i></small></p>
        </div>
        <div class="form-group">
          <label for="PatientLastName"><span>Last name</span></label>
          <span class="field-validation-valid error-text" data-valmsg-for="PatientLastName" data-valmsg-replace="true"></span>
          <input class="form-control" data-val="true" data-val-length="Last Name must be atleast 0 characters long." data-val-length-max="100" data-val-regex="Last Name is invalid." data-val-regex-pattern="^[a-zA-Z- .'_\- 0-9]+$"
            data-val-required="Last Name field is required" id="PatientLastName" maxlength="100" name="PatientLastName" required="required" type="text" value="">
        </div>
      </div>
      <div class="col-md-6">
        <div class="form-group">
          <label for="emailAddress"><span>Email (Optional)</span></label>
          <span class="field-validation-valid error-text" data-valmsg-for="VmEmailAddress.EmailAddress" data-valmsg-replace="true"></span>
          <input class="form-control input-field" autocomplete="off" data-val="true" data-val-email="The Email Address field is not a valid e-mail address." data-val-length="Email Address cannot exceed maximum length of 100 characters."
            data-val-length-max="100" data-val-remote="The email address entered is invalid. It has appeared in our system as a bounced email. Please enter a valid email address." data-val-remote-additionalfields="*.EmailAddress,*.IsExistsCheck"
            data-val-remote-type="POST" data-val-remote-url="/Misc/IsValidEmail" id="EmailAddress" maxlength="50" name="VmEmailAddress.EmailAddress" oncopy="return false;" oncut="return false;" ondrag="return false;" ondrop="return false;"
            onpaste="return false;" type="text" value="">
        </div>
        <div class="form-group">
          <label for="confirmEmailAddress"><span>Confirm email address</span></label>
          <span class="field-validation-valid error-text" data-valmsg-for="VmEmailAddress.ConfirmEmail" data-valmsg-replace="true"></span>
          <input class="form-control input-field" autocomplete="off" data-val="true" data-val-email="The Email Address field is not a valid e-mail address." data-val-equalto="Emails do not match." data-val-equalto-other="*.EmailAddress"
            data-val-length="Email Address cannot exceed maximum length of 100 characters." data-val-length-max="100" id="ConfirmEmail" maxlength="50" name="VmEmailAddress.ConfirmEmail" oncopy="return false;" oncut="return false;"
            ondrag="return false;" ondrop="return false;" onpaste="return false;" type="text" value="">
        </div>
      </div>
      <input data-val="true" data-val-number="The field PatientId must be a number." data-val-required="The PatientId field is required." id="PatientId" name="PatientId" type="hidden" value="39865663">
    </div>
  </div>
  <div class="text-center desk-text-right m-t-30">
    <button type="button" id="btnNextStep" class="btn btn-default center-block desk-pull-right width-280 m-t-30 m-t-md-20 m-b-30 disable">Next</button>
  </div>
</form>

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PATIENT INFORMATION

All fields are required
Date of birth Date of birth field is required

(Format: MM/DD/YYYY)

Last name
Email (Optional)
Confirm email address
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AdaptHealthNC GP

email: 
insurancechange@adapthealth.com
phone: 
(844) 292-1008
PO Box 745935
Los Angeles, California
90074-5935
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