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https://app.smartsheet.com/b/form/d22d72cd3449468ba2acf5ca3ff1115a
Submission Tags: falconsandbox
Submission: On April 20 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On April 20 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p>This form is required to be completed by a client when requesting claims to be sent by True Rx to any vendor (data analytic firms, stop loss vendors, data warehouses, etc.) </p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Client Name" data-client-type="text" id="8zRrrDk" class="css-1e3khfm ef83ajd0"><label for="text_box_Client Name" data-client-id="label_Client Name" class="css-1xl1v40 ekxsfat0">Client Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Client Name" data-client-id="text_box_Client Name" data-client-type="" name="8zRrrDk" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contact" data-client-type="text" id="jkdllpe" class="css-1e3khfm ef83ajd0"><label for="text_box_Contact" data-client-id="label_Contact" class="css-1xl1v40 ekxsfat0">Contact<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Contact" class="rich-text-field-desc">
<p>Individual at Client granting permission for True Rx Health Strategists to send claims data to vendor of choice</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_Contact" tabindex="0" id="text_box_Contact" data-client-id="text_box_Contact" data-client-type="" name="jkdllpe" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Title" data-client-type="text" id="lkpDDnv" class="css-1e3khfm ef83ajd0"><label for="text_box_Title" data-client-id="label_Title" class="css-1xl1v40 ekxsfat0">Title<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Title" data-client-id="text_box_Title" data-client-type="" name="lkpDDnv" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Email" data-client-type="text" id="bdRZZ6G" class="css-1e3khfm ef83ajd0"><label for="text_box_Email" data-client-id="label_Email" class="css-1xl1v40 ekxsfat0">Email<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Email" data-client-id="text_box_Email" data-client-type="" name="bdRZZ6G" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Vendor" data-client-type="text" id="DvnbbPr" class="css-1e3khfm ef83ajd0"><label for="text_box_Vendor" data-client-id="label_Vendor" class="css-1xl1v40 ekxsfat0">Vendor<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Vendor" class="rich-text-field-desc">
<p>Vendor client is requesting claims to be sent </p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_Vendor" tabindex="0" id="text_box_Vendor" data-client-id="text_box_Vendor" data-client-type="" name="DvnbbPr" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Today's Date" data-client-type="date" id="O1J33Kq" class="css-gbq6lm ef83ajd0"><label for="date_Today's Date" data-client-id="label_Today's Date" class="css-1xl1v40 ekxsfat0">Today's Date</label>
<div class="css-1f92r3b"><input data-client-id="date_Today's Date" id="date_Today's Date" aria-label="Today's Date" tabindex="0" name="Today's Date" maxlength="100" class="css-1dpiipj epidubd0" value=""><button tabindex="0" type="button"
aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
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<path fill="#FFF"
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</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1y93uaa excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-oltpmt e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-ybae4b e8i4qwl0">
<div class="css-1kw6mnl e8i4qwl1"><a target="_blank" href="https://www.smartsheet.com/legal/privacy" rel="noopener noreferrer" data-client-id="footer_privacy" class="css-a7ff3e e8i4qwl2"><span>Privacy Notice</span></a><span
style="margin: 0px 5px;">|</span><a target="_blank" href="https://app.smartsheet.com/b/reportabuse?EQBCT=d22d72cd3449468ba2acf5ca3ff1115a" rel="noopener noreferrer" data-client-id="footer_reportAbuse" class="css-a7ff3e e8i4qwl2"><span>Report Abuse</span></a>
</div>
</div>
</form>Text Content
Client Claims Release Form This form is required to be completed by a client when requesting claims to be sent by True Rx to any vendor (data analytic firms, stop loss vendors, data warehouses, etc.) Client Name* Contact* Individual at Client granting permission for True Rx Health Strategists to send claims data to vendor of choice Title* Email* Vendor* Vendor client is requesting claims to be sent Today's Date Calendar IconCalendar -------------------------------------------------------------------------------- Send me a copy of my responses Submit Privacy Notice|Report Abuse