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360smartercare.gomohealth.care Open in urlscan Pro
20.49.97.0  Public Scan

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URL: https://360smartercare.gomohealth.care/contact/victaulic/
Submission: On September 15 via manual from US — Scanned from DE

Form analysis 2 forms found in the DOM

GET https://360smartercare.gomohealth.care/

<form role="search" class="searchform fusion-search-form  fusion-search-form-clean" method="get" action="https://360smartercare.gomohealth.care/">
  <div class="fusion-search-form-content">
    <div class="fusion-search-field search-field">
      <label><span class="screen-reader-text">Search for:</span>
        <input type="search" value="" name="s" class="s" placeholder="Search..." required="" aria-required="true" aria-label="Search...">
      </label>
    </div>
    <div class="fusion-search-button search-button">
      <input type="submit" class="fusion-search-submit searchsubmit" aria-label="Search" value="">
    </div>
  </div>
</form>

POST /contact/victaulic/

<form method="post" enctype="multipart/form-data" id="gform_10" action="/contact/victaulic/">
  <div class="gform_body">
    <ul id="gform_fields_10" class="gform_fields top_label form_sublabel_below description_below">
      <li id="field_10_1" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_1" id="input_10_1" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
      <li id="field_10_2" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_2" id="input_10_2" type="hidden" class="gform_hidden" aria-invalid="false"
          value="https://360smartercare.gomohealth.care/contact/victaulic/"></li>
      <li id="field_10_3" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_3" id="input_10_3" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
      <li id="field_10_4" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">
        <p>Complete the form below to receive important information and updates on the 360 Smarter Care program:</p>
      </li>
      <li id="field_10_5" class="gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Name<span class="gfield_required">*</span></label>
        <div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_10_5">
          <span id="input_10_5_3_container" class="name_first">
            <input type="text" name="input_5.3" id="input_10_5_3" value="" aria-label="First name" aria-required="true" aria-invalid="false">
            <label for="input_10_5_3">First</label>
          </span>
          <span id="input_10_5_6_container" class="name_last">
            <input type="text" name="input_5.6" id="input_10_5_6" value="" aria-label="Last name" aria-required="true" aria-invalid="false">
            <label for="input_10_5_6">Last</label>
          </span>
        </div>
      </li>
      <li id="field_10_6" class="gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How would you like to receive information about the 360 Smarter Care
          program?<span class="gfield_required">*</span></label>
        <div class="ginput_container ginput_container_checkbox">
          <ul class="gfield_checkbox" id="input_10_6">
            <li class="gchoice_10_6_1">
              <input name="input_6.1" type="checkbox" value="Text Message" id="choice_10_6_1">
              <label for="choice_10_6_1" id="label_10_6_1">Text Message</label>
            </li>
            <li class="gchoice_10_6_2">
              <input name="input_6.2" type="checkbox" value="Email" id="choice_10_6_2">
              <label for="choice_10_6_2" id="label_10_6_2">Email</label>
            </li>
          </ul>
        </div>
      </li>
      <li id="field_10_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_10_7">Mobile Phone Number<span
            class="gfield_required">*</span></label>
        <div class="ginput_container ginput_container_phone"><input name="input_7" id="input_10_7" type="text" value="" class="medium" placeholder="(555) 555-5555" aria-required="true" aria-invalid="false" disabled=""></div>
      </li>
      <li id="field_10_8" class="gfield custom_font_p gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;">
        <p>You’ll receive up to 1-2 messages/week from the number 43386. Message and Data rates may apply according to your carrier). You may opt out of receiving text messages at any time by texting “STOP” 43386.</p>
      </li>
      <li id="field_10_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_10_9">Email Address<span
            class="gfield_required">*</span></label>
        <div class="ginput_container ginput_container_email">
          <input name="input_9" id="input_10_9" type="text" value="" class="medium" placeholder="youremail@website.com" aria-required="true" aria-invalid="false" disabled="">
        </div>
      </li>
      <li id="field_10_10" class="gfield custom_font_p gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;">
        <p>You’ll receive up to 1-2 messages/week via email from <a href="mailto:noreply@360smartercare.gomohealth.care">noreply@360smartercare.gomohealth.care</a>. You may unsubscribe at any time by clicking the Unsubscribe link in the email.</p>
      </li>
      <li id="field_10_11" class="gfield mt_25 chk_full_width gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Terms and Conditions<span
            class="gfield_required">*</span></label>
        <div class="ginput_container ginput_container_checkbox">
          <ul class="gfield_checkbox" id="input_10_11">
            <li class="gchoice_10_11_1">
              <input name="input_11.1" type="checkbox"
                value="I have read and accepted the <a href=&quot;https://360smartercare.gomohealth.care/terms/&quot;>Terms &amp; Conditions</a> and agree to receive email/text messages about the 360 Smarter Care program." id="choice_10_11_1">
              <label for="choice_10_11_1" id="label_10_11_1">I have read and accepted the <a href="https://360smartercare.gomohealth.care/terms/">Terms &amp; Conditions</a> and agree to receive email/text messages about the 360 Smarter Care
                program.</label>
            </li>
          </ul>
        </div>
      </li>
    </ul>
  </div>
  <div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_10" class="gform_button button" value="Submit" onclick="if(window[&quot;gf_submitting_10&quot;]){return false;}  window[&quot;gf_submitting_10&quot;]=true;  "
      onkeypress="if( event.keyCode == 13 ){ if(window[&quot;gf_submitting_10&quot;]){return false;} window[&quot;gf_submitting_10&quot;]=true;  jQuery(&quot;#gform_10&quot;).trigger(&quot;submit&quot;,[true]); }">
    <input type="hidden" class="gform_hidden" name="is_submit_10" value="1">
    <input type="hidden" class="gform_hidden" name="gform_submit" value="10">
    <input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
    <input type="hidden" class="gform_hidden" name="state_10" value="WyJbXSIsIjI4OGJiZjIyYWI5ZDFhYjgzOTIwYTUwODNlODQ2YzBlIl0=">
    <input type="hidden" class="gform_hidden" name="gform_target_page_number_10" id="gform_target_page_number_10" value="0">
    <input type="hidden" class="gform_hidden" name="gform_source_page_number_10" id="gform_source_page_number_10" value="1">
    <input type="hidden" name="gform_field_values" value="">
  </div>
</form>

Text Content

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Search for:


 * Terms & Conditions
 * How it Works
 * Benefits
 * How to Submit Claims
 * Emergency Department vs. Urgent Care



 * Terms & Conditions
 * How it Works
 * Benefits
 * How to Submit Claims
 * Emergency Department vs. Urgent Care





360 SMARTER CARE: CONTACT FORM

 * 
 * 
 * 

 * Complete the form below to receive important information and updates on the
   360 Smarter Care program:

 * Name*
   First Last
 * How would you like to receive information about the 360 Smarter Care
   program?*
    * Text Message
    * Email

 * Mobile Phone Number*
   

 * You’ll receive up to 1-2 messages/week from the number 43386. Message and
   Data rates may apply according to your carrier). You may opt out of receiving
   text messages at any time by texting “STOP” 43386.

 * Email Address*
   

 * You’ll receive up to 1-2 messages/week via email from
   noreply@360smartercare.gomohealth.care. You may unsubscribe at any time by
   clicking the Unsubscribe link in the email.

 * Terms and Conditions*
    * I have read and accepted the Terms & Conditions and agree to receive
      email/text messages about the 360 Smarter Care program.



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and Conditions.

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