www.conehealthwallet.com Open in urlscan Pro
65.9.86.22 Public Scan

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URL:
https://www.conehealthwallet.com/
Submission: On February 22 via automatic, source certstream-suspicious (February 22nd 2023, 2:09:50 am UTC) — Scanned from DE

Form analysis
23 forms found in the DOM

Name: forms.createForm —

<form name="forms.createForm" novalidate="novalidate">
  <div class="split-input-areas-container">
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="person-genderless" for="register-first" size="sm" class="iconic icon-for-input">
            <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
          </svg></span> <input required="required" name="firstName" type="text" id="register-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
      <div class="input-area-feedback"><!----></div>
    </div>
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="person-genderless" for="register-last" size="sm" class="iconic icon-for-input">
            <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
          </svg></span> <input required="required" name="lastName" type="text" id="register-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon"></div>
      <div class="input-area-feedback"><!----></div>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="register-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="register-email" placeholder="Email Address" on-email-check-finished="asyncValidationComplete" tabindex="3"
        maxlength="255" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" for="create-phone" size="sm" class="iconic icon-for-input">
          <path fill="#939598"
            d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
          </path>
        </svg></span> <input name="phone" type="text" id="create-phone" phone-number="" sms-eligible="" placeholder="Mobile Phone" tabindex="4" maxlength="12" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="input-area-wrapper login-password-input-area">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="register-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="password" type="password" id="register-pass" maxlength="255" placeholder="Password" tabindex="5" class="fs-block input-with-icon"></div>
    <div class="input-area-rules">
      <ul>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 8 characters </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 uppercase letter </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 number </li>
      </ul>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="register-con-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="confirmPassword" type="password" id="register-con-pass" placeholder="Confirm Password" tabindex="6" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="register-checkboxes">
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="receivesSms" name="receivesSms" type="checkbox" tabindex="7"> <label for="receivesSms" class="create-account-terms">Text me new bills &amp; reminders</label>
      </div>
    </div>
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper no-initial-border inline-input-type"><input required="required" id="tou" name="tou" type="checkbox" tabindex="8"> <label for="tou" class="create-account-terms">I agree to the
          <a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
      <div class="input-area-feedback"><!----></div>
    </div>
  </div> <button tabindex="8" class="button button-primary">Create Account</button> <!----> <!---->
</form>

Name: forms.loginForm —

<form name="forms.loginForm" novalidate="novalidate"><!---->
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="login-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input name="email" type="email" required="required" id="login-email" autocapitalize="off" maxlength="255" placeholder="Email Address" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="login-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input name="password" type="password" required="required" id="login-pass" placeholder="Password" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div> <button class="button button-primary">Log In</button> <button class="button button-secondary">Forgot Your Password?</button>
</form>

Name: forms.forgotForm —

<form name="forms.forgotForm" novalidate="novalidate">
  <div class="input-area-wrapper forgot-email-input">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="forgot-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input name="email" type="email" required="required" maxlength="255" id="forgot-email" autocapitalize="off" on-email-check-finished="emailRegisteredCheckFinished" ng-model-options="{ updateOn: 'blur submit' }"
        placeholder="Email Address" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div> <button class="button button-primary"> Next </button>
</form>

Name: forms.methodForm —

<form name="forms.methodForm" novalidate="novalidate">
  <div class="contact-method"><button class="button button-primary button-block u-truncate fs-block" style="display: none;"> Email me (null) </button> <button class="button button-primary button-block fs-block" style="display: none;"> Text me (null)
    </button></div>
</form>

Name: forms.verifyForm —

<form name="forms.verifyForm" novalidate="novalidate">
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><input name="code" type="text" all-numeric="" required="required" placeholder="Verification Code" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}" maxlength="6" autocomplete="off"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="modal-actions"><button type="button" class="button button-secondary"> I didn't receive a code </button> <button class="button button-primary"> Next </button></div>
</form>

Name: forms.resetPasswordForm —

<form name="forms.resetPasswordForm" novalidate="novalidate"><!---->
  <div class="input-area-wrapper login-password-input-area">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="reset-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="password" type="password" valid-password="" id="reset-pass" maxlength="255" placeholder="New Password" tabindex="2" class="fs-block input-with-icon"></div>
    <div class="input-area-rules">
      <ul>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 8 characters </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 uppercase letter </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 number </li>
      </ul>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="reset-con-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="confirmPassword" type="password" id="reset-con-pass" match="resetPassword.password" valid-password="" placeholder="Confirm Password" tabindex="3" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div> <button tabindex="4" class="button button-primary"> Reset Password </button>
</form>

Name: forms.composeForm —

<form novalidate="novalidate" name="forms.composeForm" class="v-form">
  <div class="form-title">New Message</div>
  <div>
    <div>
      <div data-testid="compose-message-provider-list">
        <div class="vuetify compose-options-listing">
          <div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
            <div class="v-input__control">
              <div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-22" class="v-input__slot">
                <fieldset aria-hidden="true">
                  <legend style="width: 0px;"><span></span></legend>
                </fieldset>
                <div class="v-select__slot"><label for="input-22" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Provider</label>
                  <div class="v-select__selections"><input required="required" disabled="disabled" id="input-22" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
                  <div class="v-input__append-inner">
                    <div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
                          class="v-icon__svg">
                          <path d="M7,10L12,15L17,10H7Z"></path>
                        </svg></span></div>
                  </div><input type="hidden">
                </div>
                <div class="v-menu"><!----></div>
              </div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div>
      <div data-testid="compose-message-account-list">
        <div class="vuetify compose-options-listing">
          <div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
            <div class="v-input__control">
              <div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-26" class="v-input__slot">
                <fieldset aria-hidden="true">
                  <legend style="width: 0px;"><span></span></legend>
                </fieldset>
                <div class="v-select__slot"><label for="input-26" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select an Account</label>
                  <div class="v-select__selections"><input required="required" disabled="disabled" id="input-26" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
                  <div class="v-input__append-inner">
                    <div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
                          class="v-icon__svg">
                          <path d="M7,10L12,15L17,10H7Z"></path>
                        </svg></span></div>
                  </div><input type="hidden">
                </div>
                <div class="v-menu"><!----></div>
              </div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-testid="compose-message-reasons-list">
      <div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
        <div class="v-input__control">
          <div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-29" class="v-input__slot">
            <fieldset aria-hidden="true">
              <legend style="width: 0px;"><span></span></legend>
            </fieldset>
            <div class="v-select__slot"><label for="input-29" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Reason</label>
              <div class="v-select__selections"><input required="required" disabled="disabled" id="input-29" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
              <div class="v-input__append-inner">
                <div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
                      class="v-icon__svg">
                      <path d="M7,10L12,15L17,10H7Z"></path>
                    </svg></span></div>
              </div><input type="hidden" value="[object Object]">
            </div>
            <div class="v-menu"><!----></div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div>
    <div
      class="v-input vuetify compose-message-textarea fs-block v-textarea v-textarea--auto-grow v-textarea--no-resize v-input--hide-details theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-text-field--placeholder">
      <div class="v-input__control">
        <div class="v-input__slot">
          <fieldset aria-hidden="true">
            <legend style="width: 0px;"><span></span></legend>
          </fieldset>
          <div class="v-text-field__slot"><label for="input-32" class="v-label theme--light" style="left: 0px; right: auto; position: absolute;">Message</label><textarea name="message" required="required" maxlength="5000" id="input-32" rows="5"
              style="height: 125px;"></textarea></div>
        </div>
      </div>
    </div>
  </div>
  <div class="" style="display: none;">
    <div class="vuetify keep-right attachment-button"><button type="button" class="button-secondary vuetify no-capitalization v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-attach-button" style="display: none;"><span
          class="v-btn__content">Attach a file <span aria-hidden="true" class="v-icon notranslate v-icon--right theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true" class="v-icon__svg">
              <path
                d="M7.5,18A5.5,5.5 0 0,1 2,12.5A5.5,5.5 0 0,1 7.5,7H18A4,4 0 0,1 22,11A4,4 0 0,1 18,15H9.5A2.5,2.5 0 0,1 7,12.5A2.5,2.5 0 0,1 9.5,10H17V11.5H9.5A1,1 0 0,0 8.5,12.5A1,1 0 0,0 9.5,13.5H18A2.5,2.5 0 0,0 20.5,11A2.5,2.5 0 0,0 18,8.5H7.5A4,4 0 0,0 3.5,12.5A4,4 0 0,0 7.5,16.5H17V18H7.5Z">
              </path>
            </svg></span></span></button></div> <input type="file" focus="0" accept=".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.txt" multiple="multiple" class="fs-block" style="display: none;">
    <div style="display: none;">
      <div data-testid="compose-message-message-attachments" class="message-attachments fs-block"></div>
    </div> <!---->
  </div>
  <div class="vuetify keep-right form-buttons"><button type="button" class="button-bigger-text vuetify v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-cancel-button"><span class="v-btn__content">Cancel</span></button>
    <button type="button" disabled="disabled" class="button-bigger-text vuetify v-button-primary v-btn v-btn--disabled v-btn--has-bg theme--light v-size--default" data-testid="compose-message-send-button"><span
        class="v-btn__content">SEND</span></button></div>
</form>

Name: forms.scEmailForm —

<form name="forms.scEmailForm" novalidate="novalidate"><!---->
  <div class="modal-text">Please enter your email address:</div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="contact-bill-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-bill-email" placeholder="Email Address" tabindex="1" maxlength="255" class="fs-block input-with-icon">
    </div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="modal-text">Please enter your bill details:</div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 36.5 36.5" name="bill-scode" for="contact-bill-scode" size="sm" class="iconic">
        <circle fill="#08A650" cx="18.2" cy="18.3" r="18"></circle>
        <path fill="#FFF" d="M23.5 17.2H11.8c0 1.8-.1 4.1-.2 6-.2 4.4 3.5 6.7 7.1 6.5 4.2-.2 5-4.7 5-4.7s-.2-4.4-.2-7.8M17.9 11.3l-5.1-.1c-.9.3-1 2-1 2V16H18l-.1-4.7zM23.5 16c0-1 0-1.8.1-2.2.2-1.9-1.4-2.4-1.4-2.4h-3c0 1.7.1 4 .1 4.7l4.2-.1z"></path>
        <path fill="none" stroke="#FFF" stroke-width="1.424" stroke-miterlimit="10" d="M17.8 10.7C17.6 6 23.1 6 23.1 6"></path>
      </svg> <input type="text" required="required" id="contact-bill-scode" tabindex="2" name="scode" autocomplete="off" placeholder="SecureHealthCode on Bill" maxlength="11" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div autocomplete="off" class="input-area-wrapper">
    <div class="input-area-field-wrapper"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 36.5 20.5" name="bill-amount" for="contact-bill-amount" size="sm" class="iconic">
        <path fill="#10356B" d="M.6 20.1c-.2.1-.3-.1-.3-.2V7.5c0-.1.1-.2.2-.2C2.2 6.6 16.4 1 18.2.3h.3c1.7.7 16 6.3 17.7 7 .1 0 .2.1.2.2v12.4c0 .2-.2.3-.3.2l-17.5-6.8h-.4L.6 20.1z"></path>
      </svg> <input tabindex="3" type="text" id="contact-bill-amount" name="billAmount" required="required" maxlength="20" placeholder="Total Balance Due on Bill" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div> <button tabindex="4" class="button-primary">Verify</button> <button type="button" tabindex="5" class="button">Back</button>
</form>

Name: forms.createForm —

<form name="forms.createForm" novalidate="novalidate">
  <h2 class="modal-header">Almost there...</h2>
  <div class="modal-text">Please create a password:</div>
  <div class="input-area-wrapper login-password-input-area">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="contact-register-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="password" type="password" valid-password="" id="contact-register-pass" maxlength="255" placeholder="Password" tabindex="4" class="fs-block input-with-icon"></div>
    <div class="input-area-rules">
      <ul>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 8 characters </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 uppercase letter </li>
        <li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
              name="shape-circle" size="sm" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
            </svg></span> 1 number </li>
      </ul>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="contact-register-con-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="confirmPassword" type="password" id="contact-register-con-pass" placeholder="Confirm Password" tabindex="5" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback">
      <div class="vue-messages">
        <div class="vue-message"> Please complete this field to continue. </div>
      </div>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper no-initial-border"><input required="required" name="tou" id="contact-tou" type="checkbox" tabindex="6"> <label for="contact-tou" class="create-account-terms">I agree to the
        <a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
    <div class="input-area-feedback">
      <div class="vue-messages">
        <div class="vue-message"> For legal reasons, we require all users to accept our Terms of Use. </div>
      </div>
    </div>
  </div> <button tabindex="7" class="button button-primary">Submit</button> <button tabindex="8" type="button" class="button">Back</button>
</form>

Name: forms.loginForm —

<form name="forms.loginForm" novalidate="novalidate">
  <h2 class="modal-header">Almost there...</h2> <!---->
  <div class="modal-text"> Please log in to your account: </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="contact-login-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input tabindex="1" name="email" type="email" required="required" autocapitalize="off" maxlength="255" placeholder="Email Address" id="contact-login-email" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="contact-login-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input id="contact-login-pass" tabindex="2" name="password" type="password" required="required" placeholder="Password" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="login-forgot-password-link"><a href="" tabindex="3">
                    Forgot Your Password?
                </a></div> <button tabindex="4" class="button button-primary">Submit</button> <button tabindex="5" type="button" class="button">Back</button>
</form>

Name: forms.contactForm —

<form name="forms.contactForm" novalidate="novalidate">
  <div class="split-input-areas-container">
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="person-genderless" for="contact-zendesk-first" size="sm" class="iconic icon-for-input">
            <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
          </svg></span> <input required="required" name="firstName" type="text" id="contact-zendesk-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
      <div class="input-area-feedback"><!----></div>
    </div>
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="person-genderless" for="contact-zendesk-last" size="sm" class="iconic icon-for-input">
            <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
          </svg></span> <input required="required" name="lastName" type="text" id="contact-zendesk-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon"></div>
      <div class="input-area-feedback"><!----></div>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="contact-zendesk-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-zendesk-email" placeholder="Email Address" tabindex="3" maxlength="255" class="fs-block input-with-icon">
    </div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper no-initial-border"><textarea required="required" maxlength="5000" name="message" placeholder="Start typing your message..." tabindex="4" class="fs-block"></textarea></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <p class="info">For your security, please exclude personal health information.</p>
  <div class="form-error"><!----></div> <button tabindex="5" class="button-primary">Send Message</button> <button tabindex="6" type="button" class="button">Back</button>
</form>

Name: forms.verifyEmailCodeForm —

<form name="forms.verifyEmailCodeForm" novalidate="novalidate">
  <div class="interaction-feedback vue-messages"><!----></div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><input name="emailVerificationCode" type="text" inputmode="decimal" required="required" placeholder="Verification Code" tabindex="0" maxlength="6"> <a class="inline">Resend</a></div>
    <div class="input-area-feedback">
      <div class="vue-messages">
        <div class="vue-message" style="display: none;"> Please complete this field to continue. </div>
      </div>
    </div>
  </div>
</form>

Name: forms.feedbackForm —

<form name="forms.feedbackForm" novalidate="novalidate" class="form-clean">
  <div class="comment-prompt"></div> <!---->
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper no-initial-border inline-input-type"><textarea placeholder="Start typing feedback..." maxlength="5000" class="fs-block"></textarea></div>
  </div> <button id="submit-feedback" class="button-primary">Send Feedback</button>
</form>

Name: forms.verifyAcctForm —

<form name="forms.verifyAcctForm" novalidate="novalidate">
  <h2 class="modal-header h-style-2"></h2>
  <h3 class="modal-subheader h-style-4"></h3>
  <div class="interaction-feedback" style="display: none;"></div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><input type="text" pastdate="" required="required" maxlength="10" autocomplete="off" name="birthdate" placeholder="Date of Birth (MM/DD/YYYY)" class="fs-block"></div>
    <div class="input-area-feedback">
      <div style="display: none;"><!----></div>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><input type="text" name="SSN" required="required" minlength="4" maxlength="4" inputmode="decimal" placeholder="Last Four Digits of Social Security Number" autocomplete="off" class="fs-block"></div>
    <div class="input-area-feedback">
      <div class="vue-messages"><!----></div>
    </div>
  </div>
  <div class="SSN-help-text explanation-text" style="display: none;"><b>Note:</b> If you're adding accounts for an infant, use the guarantor's SSN</div> <button class="button-primary button-callout submit-button"></button>
</form>

Name: forms.confirmPhoneForm —

<form name="forms.confirmPhoneForm" novalidate="novalidate">
  <h2 class="modal-header h-style-2">Complete Account Registration</h2>
  <h3 class="modal-subheader h-style-4">Please verify your mobile phone number.</h3>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" size="sm" class="iconic icon-for-input">
          <path fill="#939598"
            d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
          </path>
        </svg></span> <input name="phoneNumber" type="text" required="required" placeholder="Mobile Phone" tabindex="0" maxlength="12" class="input-with-icon fs-block"></div>
    <div class="input-area-feedback"><!----></div> <span>
      <div>You will receive a text message with a unique code to verify your mobile phone number.</div>
    </span>
  </div>
</form>

Name: forms.verifyCodeForm —

<form name="forms.verifyCodeForm" novalidate="novalidate" style="display: none;">
  <h2 class="modal-header h-style-2">Complete Account Registration</h2>
  <h3 class="modal-subheader h-style-4">Please enter the code we sent to your mobile device via SMS.</h3>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><input name="code" type="text" required="required" placeholder="Verification Code" tabindex="0" maxlength="6" autocomplete="off"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
</form>

Name: forms.confirmEmailForm —

<form name="forms.confirmEmailForm" novalidate="novalidate">
  <h2 class="modal-header h-style-2">Verify Email Address</h2>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
          viewBox="0 0 16 16" name="envelope-closed" for="details-email" size="sm" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input required="required" placeholder="Email Address" id="details-email" name="email" type="email" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback">
      <div class="vue-messages"><!----> <!----> <!----></div>
    </div> <span class="explanation">Is the email address listed correct? If not, please correct it above prior to clicking the "Send Email" button to update your account.</span>
  </div>
</form>

Name: forms.echeckForm —

<form novalidate="" name="forms.echeckForm" ng-submit="method.submitAndMove()" class="ng-pristine ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength ng-valid-mismatch">
  <div class="split-input-areas-container">
    <!-- FIRST NAME -->
    <div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.firstName.$invalid &amp;&amp; forms.echeckForm.$submitted}">
      <div class="input-area-field-wrapper">
        <input sensitive="" valid-name="" type="text" required="" name="firstName" ng-model="method.eCheck.firstName" placeholder="First Name" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
      </div>
      <div class="input-area-feedback">
        <div ng-messages="forms.echeckForm.firstName.$error" class="ng-active">
          <!-- ngMessage: required -->
          <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
        </div>
      </div>
    </div>
    <!-- LAST NAME -->
    <div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.lastName.$invalid &amp;&amp; forms.echeckForm.$submitted}">
      <div class="input-area-field-wrapper">
        <input sensitive="" valid-name="" type="text" required="" name="lastName" ng-model="method.eCheck.lastName" placeholder="Last Name" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
      </div>
      <div class="input-area-feedback">
        <div ng-messages="forms.echeckForm.lastName.$error" class="ng-active">
          <!-- ngMessage: required -->
          <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
        </div>
      </div>
    </div>
  </div>
  <!-- ROUTING NUMBER -->
  <div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.routing.$invalid &amp;&amp; (forms.echeckForm.routing.$error.validRouting || forms.echeckForm.$submitted)}">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="tel" name="routing" required="" ng-minlength="9" maxlength="9" all-numeric="" routing-number="" on-bank-found="method.applyBank(bankName)" ng-model="method.eCheck.routing" placeholder="Routing Number"
        on-routing-number-check-finished="routingNumberValidated" class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
    </div>
    <div class="input-area-feedback">
      <!-- ngIf: forms.echeckForm.routing.$invalid && (forms.echeckForm.routing.$error.validRouting || forms.echeckForm.$submitted) -->
    </div>
  </div>
  <div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.accountNumber.$invalid &amp;&amp; forms.echeckForm.$submitted}">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="tel" required="" maxlength="25" ng-minlength="4" name="accountNumber" all-numeric="" ng-cut="$event.preventDefault()" ng-copy="$event.preventDefault()" ng-model="method.eCheck.accountNumber"
        placeholder="Account Number" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
    </div>
    <div class="input-area-feedback">
      <div ng-messages="forms.echeckForm.accountNumber.$error" class="ng-active">
        <!-- ngMessage: required -->
        <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
        <!-- ngMessage: minlength -->
      </div>
    </div>
  </div>
  <div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.accountNumberConfirm.$invalid &amp;&amp; forms.echeckForm.$submitted}">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="tel" maxlength="25" ng-minlength="4" all-numeric="" ng-cut="$event.preventDefault()" ng-copy="$event.preventDefault()" ng-paste="$event.preventDefault()" name="accountNumberConfirm" required=""
        match="method.eCheck.accountNumber" ng-model="method.eCheck.accountNumberConfirm" placeholder="Confirm Account Number"
        class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength ng-valid-mismatch">
    </div>
    <div class="input-area-feedback">
      <div ng-messages="forms.echeckForm.accountNumberConfirm.$error" class="ng-active">
        <!-- ngMessage: required -->
        <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
        <!-- ngMessage: mismatch -->
      </div>
    </div>
  </div>
  <button class="button-primary payment-next-step-button ng-binding"> Continue </button>
</form>

Name: forms.billing —

<form novalidate="" name="forms.billing" ng-submit="billing.submitAndMove()" class="ng-pristine ng-scope ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
  <!-- ADDRESS 1 -->
  <div class="input-area-wrapper" ng-class="{errored: forms.billing.addr1.$invalid &amp;&amp; (forms.billing.addr1.$dirty || forms.billing.$submitted)}">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="text" required="" name="addr1" ng-model="billing.fields.address" placeholder="Address" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
    </div>
    <div class="input-area-feedback">
      <div ng-messages="forms.billing.addr1.$error" class="ng-active">
        <!-- ngMessage: required -->
        <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
      </div>
    </div>
  </div>
  <!-- ADDRESS 2 -->
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="text" name="addr2" ng-model="billing.fields.address2" placeholder="Address Line 2 (optional)" class="ng-pristine ng-untouched ng-valid fs-block">
    </div>
  </div>
  <!-- CITY -->
  <div class="input-area-wrapper" ng-class="{errored: forms.billing.city.$invalid &amp;&amp; (forms.billing.city.$dirty || forms.billing.$submitted)}">
    <div class="input-area-field-wrapper">
      <input sensitive="" type="text" required="" name="city" ng-model="billing.fields.city" placeholder="City" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
    </div>
    <div class="input-area-feedback">
      <div ng-messages="forms.billing.city.$error" class="ng-active">
        <!-- ngMessage: required -->
        <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
      </div>
    </div>
  </div>
  <!-- STATE -->
  <div class="input-area-wrapper" ng-class="{errored: forms.billing.state.$invalid &amp;&amp; (forms.billing.state.$dirty || forms.billing.$submitted)}">
    <div class="input-area-field-wrapper">
      <select required="" ng-options="state.abbreviation as state.name for state in states" ng-model="billing.fields.state" name="state" ng-class="{'empty-value': !billing.fields.state}" class="ng-scope ng-invalid ng-invalid-required empty-value">
        <option value="" disabled="" class="ng-binding">Select State</option>
        <option value="0" label="Alabama">Alabama</option>
        <option value="1" label="Alaska">Alaska</option>
        <option value="2" label="Arizona">Arizona</option>
        <option value="3" label="Arkansas">Arkansas</option>
        <option value="4" label="California">California</option>
        <option value="5" label="Colorado">Colorado</option>
        <option value="6" label="Connecticut">Connecticut</option>
        <option value="7" label="Delaware">Delaware</option>
        <option value="8" label="District of Columbia">District of Columbia</option>
        <option value="9" label="Florida">Florida</option>
        <option value="10" label="Georgia">Georgia</option>
        <option value="11" label="Hawaii">Hawaii</option>
        <option value="12" label="Idaho">Idaho</option>
        <option value="13" label="Illinois">Illinois</option>
        <option value="14" label="Indiana">Indiana</option>
        <option value="15" label="Iowa">Iowa</option>
        <option value="16" label="Kansas">Kansas</option>
        <option value="17" label="Kentucky">Kentucky</option>
        <option value="18" label="Louisiana">Louisiana</option>
        <option value="19" label="Maine">Maine</option>
        <option value="20" label="Maryland">Maryland</option>
        <option value="21" label="Massachusetts">Massachusetts</option>
        <option value="22" label="Michigan">Michigan</option>
        <option value="23" label="Minnesota">Minnesota</option>
        <option value="24" label="Mississippi">Mississippi</option>
        <option value="25" label="Missouri">Missouri</option>
        <option value="26" label="Montana">Montana</option>
        <option value="27" label="Nebraska">Nebraska</option>
        <option value="28" label="Nevada">Nevada</option>
        <option value="29" label="New Hampshire">New Hampshire</option>
        <option value="30" label="New Jersey">New Jersey</option>
        <option value="31" label="New Mexico">New Mexico</option>
        <option value="32" label="New York">New York</option>
        <option value="33" label="North Carolina">North Carolina</option>
        <option value="34" label="North Dakota">North Dakota</option>
        <option value="35" label="Ohio">Ohio</option>
        <option value="36" label="Oklahoma">Oklahoma</option>
        <option value="37" label="Oregon">Oregon</option>
        <option value="38" label="Pennsylvania">Pennsylvania</option>
        <option value="39" label="Rhode Island">Rhode Island</option>
        <option value="40" label="South Carolina">South Carolina</option>
        <option value="41" label="South Dakota">South Dakota</option>
        <option value="42" label="Tennessee">Tennessee</option>
        <option value="43" label="Texas">Texas</option>
        <option value="44" label="Utah">Utah</option>
        <option value="45" label="Vermont">Vermont</option>
        <option value="46" label="Virginia">Virginia</option>
        <option value="47" label="Washington">Washington</option>
        <option value="48" label="West Virginia">West Virginia</option>
        <option value="49" label="Wisconsin">Wisconsin</option>
        <option value="50" label="Wyoming">Wyoming</option>
        <option value="51" label="American Samoa">American Samoa</option>
        <option value="52" label="Federated States of Micronesia">Federated States of Micronesia</option>
        <option value="53" label="Guam">Guam</option>
        <option value="54" label="Northern Mariana Islands">Northern Mariana Islands</option>
        <option value="55" label="Marshall Islands">Marshall Islands</option>
        <option value="56" label="Palau">Palau</option>
        <option value="57" label="Puerto Rico">Puerto Rico</option>
        <option value="58" label="Virgin Islands">Virgin Islands</option>
        <option value="59" label="Armed Forces">Armed Forces</option>
        <option value="60" label="Armed Forces Americas">Armed Forces Americas</option>
        <option value="61" label="Armed Forces Pacific">Armed Forces Pacific</option>
      </select>
    </div>
    <div class="input-area-feedback">
      <div ng-messages="forms.billing.state.$error" class="ng-active">
        <!-- ngMessage: required -->
        <div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
      </div>
    </div>
  </div>
  <!-- ZIP -->
  <div class="input-area-wrapper" ng-class="{errored: forms.billing.zip.$invalid &amp;&amp; forms.billing.$submitted}">
    <div class="input-area-field-wrapper">
      <input required="" sensitive="" type="tel" ng-model="billing.fields.zip" all-numeric="" name="zip" maxlength="5" ng-minlength="5" placeholder="Zip Code"
        class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
    </div>
    <!-- ngIf: forms.billing.$submitted -->
  </div>
  <button class="button-primary payment-next-step-button ng-binding"> Continue </button>
</form>

Name: confirmPasswordForm —

<form name="confirmPasswordForm" novalidate="novalidate">
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="current-pass" size="sm" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input required="required" name="password" type="password" maxlength="255" id="current-pass" placeholder="Password" class="input-with-icon fs-block"></div>
    <div class="input-area-feedback">
      <div class="vue-messages"><!----></div>
    </div>
  </div>
</form>

Name: forms.myChartForm —

<form name="forms.myChartForm" novalidate="novalidate">
  <h2 class="modal-header h-style-2"></h2>
  <div class="modal-text">The PatientWallet is where you'll be able to access all of your bills and make payments.<br><br>Let's check to see if you already have an account.</div>
  <div class="input-area-wrapper solo-input">
    <div class="input-area-field-wrapper"><input name="checkEmail" type="email" placeholder="Enter your email address" class="fs-block"></div>
    <div class="input-area-feedback"><!----> <!----></div>
  </div> <button id="check-for-patient-wallet-button" tabindex="8" type="submit" class="button button-primary">Search</button>
</form>

<form><!---->
  <h2 class="modal-header h-style-2"> Set Up Your PatientWallet </h2> <svg xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:cc="http://creativecommons.org/ns#" xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#"
    xmlns:svg="http://www.w3.org/2000/svg" xmlns="http://www.w3.org/2000/svg" xmlns:sodipodi="http://sodipodi.sourceforge.net/DTD/sodipodi-0.dtd" xmlns:inkscape="http://www.inkscape.org/namespaces/inkscape" version="1.1" x="0px" y="0px"
    viewBox="0 0 100 125" style="max-width: 100px; margin-bottom: -30px; fill: rgb(97, 97, 97);">
    <g transform="translate(0,-952.36218)">
      <path
        d="m 6.0000002,973.36217 a 2.0002,2.0002 0 0 0 -2,2 l 0,54.00003 a 2.0002,2.0002 0 0 0 2,2 l 87.9999998,0 a 2.0002,2.0002 0 0 0 2,-2 l 0,-54.00003 a 2.0002,2.0002 0 0 0 -2,-2 l -87.9999998,0 z m 5.4687498,4 77.0625,0 L 50,1009.7684 11.46875,977.36217 z m -3.4687498,2.28125 25.9687498,21.84378 -25.9687498,23.375 0,-45.21878 z m 83.9999998,0 0,45.21878 -25.96875,-23.375 L 92,979.64342 z m -54.9375,24.43748 11.65625,9.8125 a 2.0002,2.0002 0 0 0 2.5625,0 l 11.65625,-9.8125 25.875,23.2813 -77.625,0 25.875,-23.2813 z"
        fill-opacity="1" stroke="none" marker="none" visibility="visible" display="inline" overflow="visible" style="text-indent: 0px; text-transform: none; direction: ltr; baseline-shift: baseline; color: rgb(0, 0, 0);"></path>
    </g>
  </svg><br>
  <div data-v-113cb332="" class="notification notification-inline failure" style="display: none;">
    <div data-v-113cb332="" class="primary-icon-container u-center-vertical"><span data-v-113cb332="" class="icon-wrap"><svg data-v-113cb332="" xmlns="http://www.w3.org/2000/svg" width="28" height="28" viewBox="0 0 75.6 75.6" name="information"
          class="iconic">
          <path data-v-113cb332="" fill="#FFF"
            d="M40.4 24c-1.4 0-2.6 1.2-2.6 2.6s1.2 2.6 2.6 2.6c1.4 0 2.6-1.2 2.6-2.6S41.8 24 40.4 24zm-3.5 6.9c-2.4 0-4.3 1.9-4.3 4.3v.9h1.7v-.9c0-1 .8-1.7 1.7-1.7s1.7.9 1.7 1.7c0 2.2-3.5 9.8-3.5 12.1 0 2.3 1.9 4.3 4.3 4.3s4.3-1.9 4.3-4.3v-.9h-1.7v.9c0 1-.8 1.7-1.7 1.7-1 0-1.7-.8-1.7-1.7 0-2 3.5-9.7 3.5-12.1s-1.9-4.3-4.3-4.3z">
          </path>
          <path data-v-113cb332="" fill="#FFF" d="M37.8 1.8c-19.9 0-36 16.1-36 36s16.1 36 36 36 36-16.1 36-36-16.1-36-36-36zm0 67.8C20.3 69.6 6 55.3 6 37.8S20.3 6 37.8 6s31.8 14.2 31.8 31.8c0 17.5-14.3 31.8-31.8 31.8z"></path>
        </svg></span></div>
    <div data-v-113cb332="" class="notification-content-container u-center-vertical">
      <div data-v-113cb332="" class="notification-content"><span data-v-113cb332=""><svg data-v-113cb332="" data-icon="circle-x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="circle-x" class="iconic">
            <path data-v-113cb332="" d="M8 0a8 8 0 100 16A8 8 0 008 0zM6 4.594l2 2 2-2L11.406 6l-2 2 2 2L10 11.406l-2-2-2 2L4.594 10l2-2-2-2L6 4.594z"></path>
          </svg></span> There was a problem sending that code. Please try again. </div>
    </div>
    <div data-v-113cb332="" class="notification-close u-center-vertical"><svg data-v-113cb332="" data-icon="x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="x" size="sm"
        class="iconic">
        <path data-v-113cb332="" d="M3 .156L.156 3l1.438 1.406L5.188 8l-3.594 3.594L.156 13 3 15.844l1.406-1.438L8 10.812l3.594 3.594L13 15.844 15.844 13l-1.438-1.406L10.812 8l3.594-3.594L15.844 3 13 .156l-1.406 1.438L8 5.188 4.406 1.594 3 .156z">
        </path>
      </svg></div>
  </div>
  <div data-v-113cb332="" class="notification notification-inline success" style="display: none;">
    <div data-v-113cb332="" class="primary-icon-container u-center-vertical"><span data-v-113cb332="" class="icon-wrap"><svg data-v-113cb332="" xmlns="http://www.w3.org/2000/svg" width="28" height="28" viewBox="0 0 75.6 75.6" name="information"
          class="iconic">
          <path data-v-113cb332="" fill="#FFF"
            d="M40.4 24c-1.4 0-2.6 1.2-2.6 2.6s1.2 2.6 2.6 2.6c1.4 0 2.6-1.2 2.6-2.6S41.8 24 40.4 24zm-3.5 6.9c-2.4 0-4.3 1.9-4.3 4.3v.9h1.7v-.9c0-1 .8-1.7 1.7-1.7s1.7.9 1.7 1.7c0 2.2-3.5 9.8-3.5 12.1 0 2.3 1.9 4.3 4.3 4.3s4.3-1.9 4.3-4.3v-.9h-1.7v.9c0 1-.8 1.7-1.7 1.7-1 0-1.7-.8-1.7-1.7 0-2 3.5-9.7 3.5-12.1s-1.9-4.3-4.3-4.3z">
          </path>
          <path data-v-113cb332="" fill="#FFF" d="M37.8 1.8c-19.9 0-36 16.1-36 36s16.1 36 36 36 36-16.1 36-36-16.1-36-36-36zm0 67.8C20.3 69.6 6 55.3 6 37.8S20.3 6 37.8 6s31.8 14.2 31.8 31.8c0 17.5-14.3 31.8-31.8 31.8z"></path>
        </svg></span></div>
    <div data-v-113cb332="" class="notification-content-container u-center-vertical">
      <div data-v-113cb332="" class="notification-content"><span data-v-113cb332=""><svg data-v-113cb332="" data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="circle-check" class="iconic">
            <path data-v-113cb332="" d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
          </svg></span> Code has been sent. </div>
    </div>
    <div data-v-113cb332="" class="notification-close u-center-vertical"><svg data-v-113cb332="" data-icon="x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="x" size="sm"
        class="iconic">
        <path data-v-113cb332="" d="M3 .156L.156 3l1.438 1.406L5.188 8l-3.594 3.594L.156 13 3 15.844l1.406-1.438L8 10.812l3.594 3.594L13 15.844 15.844 13l-1.438-1.406L10.812 8l3.594-3.594L15.844 3 13 .156l-1.406 1.438L8 5.188 4.406 1.594 3 .156z">
        </path>
      </svg></div>
  </div>
  <div class="modal-text fs-block"></div> <!---->
  <div class="input-area-field-wrapper solo-input"><input name="emailVerificationCode" type="text" required="required" placeholder="Verification Code" class="fs-block"> <a class="inline">Resend</a></div>
  <div id="terms-of-use-input" class="input-area-wrapper">
    <div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="acceptTerms" name="acceptTerms" type="checkbox" tabindex="8"> <label for="acceptTerms" class="create-account-terms">I agree to the
        <a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
    <div class="input-area-feedback"><!----></div>
  </div> <button id="verify-email-button" class="button button-primary"> Verify </button>
  <div><a>Use a different email address</a></div>
</form>

Name: finishRegistrationForm —

<form name="finishRegistrationForm" novalidate="novalidate">
  <div class="split-input-areas-container">
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
            name="person-genderless" for="finishRegistration-first" class="iconic icon-for-input">
            <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
          </svg></span> <input name="firstName" type="text" id="finishRegistration-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
      <div class="input-area-feedback"><!----></div>
    </div>
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper">
        <div><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="person-genderless"
              for="finishRegistration-last" class="iconic icon-for-input">
              <path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
            </svg></span></div> <input name="lastName" type="text" id="finishRegistration-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon">
      </div>
      <div class="input-area-feedback"><!----></div>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="envelope-closed" for="finishRegistration-email" class="iconic icon-for-input">
          <path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
        </svg></span> <input name="email" type="email" disabled="disabled" autocapitalize="off" autocorrect="off" autosuggest="off" id="finishRegistration-email" placeholder="Email Address" tabindex="3" maxlength="255"
        class="fs-block input-with-icon"></div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" for="finishRegistration--phone" class="iconic icon-for-input">
          <path fill="#939598"
            d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
          </path>
        </svg></span> <input name="phone" type="text" id="finishRegistration-phone" placeholder="Mobile Phone" on-phone-check-finished="asyncValidationComplete" tabindex="4" maxlength="12" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback">
      <div class="vue-messages"><!----> <!----></div>
    </div>
  </div>
  <div class="input-area-wrapper login-password-input-area">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="finishRegistration-pass" class="iconic icon-for-input">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input name="password" type="password" id="finishRegistration-pass" maxlength="255" placeholder="Password" tabindex="5" class="fs-block input-with-icon"></div>
    <div class="input-area-rules">
      <ul>
        <li class="min-char-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
            </svg></span> 8 characters </li>
        <li class="upper-case-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
            </svg></span> 1 uppercase letter </li>
        <li class="digit-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
              <path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
            </svg></span> 1 number </li>
      </ul>
    </div>
  </div>
  <div class="input-area-wrapper">
    <div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
          name="lock-locked" for="finishRegistration-con-pass" class="iconic">
          <path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
        </svg></span> <input name="confirmPassword" type="password" id="finishRegistration-con-pass" match="" placeholder="Confirm Password" tabindex="6" class="fs-block input-with-icon"></div>
    <div class="input-area-feedback"><!----></div>
  </div>
  <div class="register-checkboxes">
    <div class="input-area-wrapper">
      <div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="finishRegistration-receivesSms" name="receivesSms" type="checkbox" tabindex="7"> <label for="finishRegistration-receivesSms" class="create-account-terms">Text
          me new bills &amp; reminders</label></div>
    </div>
  </div> <button tabindex="8" class="button button-primary"> Save </button>
</form>

Text Content

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PATIENTCO

Patientco
Enter the unique details from your bill.
We cannot find a bill matching the SecureHealthCode and total balance you've
entered. Please check to make sure your details are correct.
You have attempted to find a bill too many times. For security reasons, your
ability to search for bills has been disabled for a few minutes.

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Welcome to the PatientWallet®! We’ve partnered with your healthcare provider to
give you the simplest, most secure payment experience possible.
© 2023
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You are now being redirected to your PatientWallet®
An error occurred while attempting to redirect you to your PatientWallet®.
Please try again, and if you continue to have problems please contact your
provider.
There was a problem sending that code. Please try again.

That code was invalid or expired. Please try again.

WELCOME TO YOUR PATIENTWALLET®

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* 8 characters
* 1 uppercase letter
* 1 number

Text me new bills & reminders
I agree to the Terms of Use

Create Account

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* 1 uppercase letter
* 1 number

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contact your provider, please call {{billingPhoneNumber}}. We apologize for any
inconvenience.

I NEED HELP WITH:

Understanding my bill I need an itemized bill I lost my Patientco bill Logging
in Reset my password

I HAVE A QUESTION ABOUT:

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payments Updating Information Insurance Requesting an itemized bill Financial
assistance Estimate Other Back

LET'S GET YOU TO THE RIGHT PLACE.

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UPDATES TO TERMS OF USE
& PRIVACY POLICY

We have updated our Terms of Use and Privacy Policy to make it easier for you to
understand what information we collect and why.

As a friendly reminder, Patientco will never share your information with third
party marketers, and you can always update your Communication Preferences within
your Settings. We encourage you to review our new Terms of Use and Privacy
Policy.

To accept the new Terms of Use and Privacy Policy, click "Accept" below.

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NOTIFICATIONS

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WHICH BILL WOULD YOU LIKE TO PAY?

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ENTER DETAILS FROM YOUR NEW BILL.

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entered. Please check to make sure your details are correct.
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ability to search for bills has been disabled for a few minutes.

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WHO WOULD YOU LIKE TO VERIFY?

Note: If you're adding accounts for an infant, use the guarantor's SSN

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COMPLETE ACCOUNT REGISTRATION

PLEASE VERIFY YOUR MOBILE PHONE NUMBER.

You will receive a text message with a unique code to verify your mobile phone
number.

COMPLETE ACCOUNT REGISTRATION

PLEASE ENTER THE CODE WE SENT TO YOUR MOBILE DEVICE VIA SMS.

By verifying your phone number, you agree to allow Patientco to send you
periodic text messages on behalf of your provider for any account-related
activity. Patientco may use an automated system to send you electronic
communications including text, phone, or email. Patientco does not have a
separate charge for this service; however, subject to the terms and conditions
of your mobile carrier, message and data rates may apply. By providing your
consent to participate in this program, you approve any such charges from your
mobile carrier. You may opt out of this program at any time by emailing
Patientco at support@patientco.com.
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VERIFY EMAIL ADDRESS

Is the email address listed correct? If not, please correct it above prior to
clicking the "Send Email" button to update your account.
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Method Address Confirmation
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The PatientWallet is where you'll be able to access all of your bills and make
payments.

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BROWSER INFO

* Browser:
* Version:
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* IP:
* Location: , ,

APPLICATION INFO

* Root URL: https://www.gopatientco.com/
* Base URL: /releases/db7fa48/
* API URL: /api
* Backendless: false
* Environment: production
* Languages: [ "en", "es" ]
* Pendo Enabled: false
* Version: db7fa48

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www.conehealthwallet.com Open in urlscan Pro 65.9.86.22 Public Scan

Form analysis 23 forms found in the DOM

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Text Content

www.conehealthwallet.com Open in urlscan Pro
65.9.86.22 Public Scan

Form analysis
23 forms found in the DOM