altruahealthshare.org
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URL:
https://altruahealthshare.org/contact/
Submission: On February 24 via manual from US — Scanned from DE
Submission: On February 24 via manual from US — Scanned from DE
Form analysis
2 forms found in the DOMPOST /contact/#gf_2
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2" action="/contact/#gf_2"> <input type="hidden" class="gforms-pum"
value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body">
<ul id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_1" class="gfield 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_2_1"> <span id="input_2_1_3_container" class="name_first"> <input type="text"
name="input_1.3" id="input_2_1_3" value="" aria-label="First name" aria-required="true" aria-invalid="false"> <label for="input_2_1_3">First</label> </span> <span id="input_2_1_6_container" class="name_last"> <input type="text"
name="input_1.6" id="input_2_1_6" value="" aria-label="Last name" aria-required="true" aria-invalid="false"> <label for="input_2_1_6">Last</label> </span></div>
</li>
<li id="field_2_2" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_2">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email"> <input name="input_2" id="input_2_2" type="email" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_2_10" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_10">Phone</label>
<div class="ginput_container ginput_container_phone"><input name="input_10" id="input_2_10" type="tel" value="" class="medium" aria-invalid="false"></div>
</li>
<li id="field_2_5" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you a member of Altrua HealthShare?<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_5">
<li class="gchoice_2_5_0"><input name="input_5" type="radio" value="Yes" id="choice_2_5_0"><label for="choice_2_5_0" id="label_2_5_0">Yes</label></li>
<li class="gchoice_2_5_1"><input name="input_5" type="radio" value="No" id="choice_2_5_1"><label for="choice_2_5_1" id="label_2_5_1">No</label></li>
</ul>
</div>
</li>
<li id="field_2_6" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_2_6">Membership ID<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_6" id="input_2_6" type="text" value="" class="medium" aria-describedby="gfield_description_2_6" aria-required="true" aria-invalid="false" disabled=""></div>
<div class="gfield_description" id="gfield_description_2_6">Please enter your 9 digit membership ID.</div>
</li>
<li id="field_2_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_9">Please select a message topic.<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_select"><select name="input_9" id="input_2_9" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="The Membership">The Membership</option>
<option value="Monthly Contributions">Monthly Contributions</option>
<option value="Medical Needs">Medical Needs</option>
<option value="Provider/Physician">Provider/Physician</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_7">Message<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_7" id="input_2_7" class="textarea medium" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_2_8" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_8"></label>
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<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
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</div>
</div>
</li>
<li id="field_2_11" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_11" id="input_2_11" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_2" class="gform_button button" value="Submit"
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</form>
POST /contact/#gf_8
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_8" id="gform_8" class="sideform" action="/contact/#gf_8"> <input type="hidden" class="gforms-pum"
value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_heading"> <span class="gform_description"></span></div>
<div class="gform_body">
<ul id="gform_fields_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_1" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_1">First Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_1" id="input_8_1" type="text" value="" class="large" placeholder="First Name*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_2" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_2">Last Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_2" id="input_8_2" type="text" value="" class="large" placeholder="Last Name*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_3" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_3">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email"> <input name="input_3" id="input_8_3" type="email" value="" class="large" placeholder="Email*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_4" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_4">Phone<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_8_4" type="tel" value="" class="large" placeholder="Phone*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_18" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_18">Zip<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_number"><input name="input_18" id="input_8_18" type="number" step="any" value="" class="large" placeholder="Zip*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_6" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_6" id="input_8_6" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_8" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_8" id="input_8_8" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_9" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_9" id="input_8_9" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_10" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_10" id="input_8_10" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_11" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_11" id="input_8_11" type="hidden" class="gform_hidden" aria-invalid="false" value="AHS.com Web"></li>
<li id="field_8_15" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_15" id="input_8_15" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_16" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_16" id="input_8_16" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_17" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_17" id="input_8_17" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_20" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_20" id="input_8_20" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_21" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_21" id="input_8_21" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_8_19" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_19">Captcha</label>
<div id="input_8_19" class="ginput_container ginput_recaptcha" data-sitekey="6LcNmn4UAAAAADTquyisKmPmA5ZC5D4CgqFmFb_1" data-theme="light" data-tabindex="0" data-badge="">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
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</li>
<li id="field_8_22" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_8_22">Phone</label>
<div class="ginput_container"><input name="input_22" id="input_8_22" type="text" value="" autocomplete="off"></div>
<div class="gfield_description" id="gfield_description_8_22">This field is for validation purposes and should be left unchanged.</div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_8" class="gform_button button" value="Submit"
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Text Content
Skip to content SHARE THE CARE | PROVIDERS | SIGN IN Altrua HealthShare * How It Works * Resources Become a Member 1.888.244.3839 * * Choose A Membership * Statement of Standards * Membership Cost Calculator * Common Questions * Our Members * Healthy Living Services & Discounts * Next Steps * Affordable Care Act IT'S SIMPLE. Individuals, couples, families, churches and organizations contribute to care for one another. Find Out More 1.888.244.3839 | Become a Member * * Membership Guidelines * Forms and Medical Needs * Membership ID Card * Share the Care * Statement of Standards * Altrua Ministries * SmileShare MEMBER PORTAL Easily view your health information, submit medical needs and manage your membership. Sign In MEMBER SERVICES Access Telemedicine and other services or speak to our Member Services team. 1.833.3–Altrua (258782) 1.888.244.3839 ALTRUA HEALTHSHARE P.O. Box 90849 Austin, TX 78709-0849 BUSINESS HOURS Member Services 8:00am–6:00pm CST Negotiations 8:00am–5:00pm CST GET AN ANSWER BY EMAIL LET US KNOW IF YOU HAVE ANY QUESTIONS ABOUT ALTRUA HEALTHSHARE AND WE WILL SEND A QUICK RESPONSE BY EMAIL. * Name* First Last * Email* * Phone * Are you a member of Altrua HealthShare?* * Yes * No * Membership ID* Please enter your 9 digit membership ID. * Please select a message topic.* The MembershipMonthly ContributionsMedical NeedsProvider/PhysicianOther * Message* * * ahs_tagline * About * Contact * Altrua Ministries * Articles * Privacy * Disclaimers & Legal Altrua Ministries (dba Altrua HealthShare, dba Altrua SmileShare) is NOT an insurance company nor is the membership offered through an insurance company. Members are self-pay patients. Altrua Ministries is a 501(c)(3) nonprofit corporation. Translated content is not an exact copy and may not include all content available in English. | © 2023 Altrua HealthShare — All rights reserved EN | ES | KO * * * Powered by Google Übersetzer LEARN MORE FIND OUT HOW MUCH YOUR FAMILY COULD SAVE—NO OBLIGATION! * First Name* * Last Name* * Email* * Phone* * Zip* * * * * * * * * * * * Captcha * Phone This field is for validation purposes and should be left unchanged. X PLEASE USE THESE STEPS ON THE MULTIPLAN WEBSITE TO SEARCH THE CORRECT NETWORK. STEP 1 Select the Network (or Change Network): PHCS STEP 2 Select the Statement: I DON’T SEE ANY OF THESE STATEMENTS STEP 3 For logo placement on ID Card select: FRONT Open Provider Search × ORIGINALTEXT Bessere Übersetzung vorschlagen --------------------------------------------------------------------------------