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Submitted URL: https://click.e.vsp.com/?qs=43f1652f66a4fafc0ef709d8a00a8f016fedf08583f473f22ff7845586f94d7795a3e373bf84a3e92234fe686f89...
Effective URL: https://www.vsp.com/contact-us/email-customer-service?elqTrackId=8ad55acc43a34214ac06cde75c46e2a1&elqTrack=true&utm_...
Submission: On March 11 via api from CH — Scanned from DE
Effective URL: https://www.vsp.com/contact-us/email-customer-service?elqTrackId=8ad55acc43a34214ac06cde75c46e2a1&elqTrack=true&utm_...
Submission: On March 11 via api from CH — Scanned from DE
Form analysis 2 forms found in the DOM
<form novalidate="" vspvalidationcontainer="" class="header-search-input-form ng-untouched ng-pristine ng-invalid"><label class="hidden-accessible" id="site-search-label" for="site-search-input">Search</label><input placeholder="Search" name="query"
minlength="3" maxlength="2048" pattern="^((?!(\d{9}|\d{3}-\d{2}-\d{4})).)*$" required="" tabindex="-1" class="form-control header-search-input ng-untouched ng-pristine ng-invalid"
id="site-search-input"><!----><a href="" tabindex="-1"><i title="Close Search" class="d-none icon-close header-search-close"></i></a></form><form novalidate="" vspvalidationcontainer="" class="mb-5 ng-untouched ng-dirty ng-invalid">
<div class="d-flex flex-wrap"><span class="what-can-we-help-you-with-headline flex-sm-100">What can we help you with?</span><vsp-form-group label="What can we help you with?" messages="Please select a help reason."
class="what-can-we-help-you-with-select flex-sm-100 mt-4 mt-md-0">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><ng-select role="listbox" aria-label="What can we help you with" id="what-can-we-help-you-with" name="whatCanWeHelpYouWith" required="" bindvalue="value"
class="ng-select ng-select-single ng-select-searchable ng-untouched ng-pristine ng-invalid">
<div class="ng-select-container">
<div class="ng-value-container">
<div class="ng-placeholder">What can we help you with?</div><!----><!---->
<div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="aa81721ec229" id="what-can-we-help-you-with-ng-select-filter-input" aria-expanded="false"></div>
</div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
</div><!---->
</ng-select></div><label class="vsp-form-group-label" id="what-can-we-help-you-with-label" for="what-can-we-help-you-with-ng-select-filter-input"> What can we help you with? </label><!----><vsp-validation-message
id="what-can-we-help-you-with-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
<div class="vsp-form">
<fieldset>
<legend class="form-section-header">Primary Member Information</legend><vsp-contact-us-member-info name="memberInfo" class="ng-untouched ng-pristine ng-valid">
<div class="row ng-star-inserted"><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-first-name" name="memberFirstName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="First Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label"
id="member-first-name-label" for="member-first-name"> First Name </label><!----><vsp-validation-message id="member-first-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-last-name" name="memberLastName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Last Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label"
id="member-last-name-label" for="member-last-name"> Last Name </label><!----><vsp-validation-message id="member-last-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Email" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="email" name="email" required="" email="" placeholder="Email" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label" id="email-label" for="email"> Email
</label><!----><vsp-validation-message id="email-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Confirm Email" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="confirm-email" name="confirmEmail" required="" placeholder="Confirm Email" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label" id="confirm-email-label" for="confirm-email">
Confirm Email </label><!----><vsp-validation-message id="confirm-email-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----><!----><vsp-date-picker label="DOB" id="birth-date" name="birthDate" class="col-md-4 ng-untouched ng-pristine ng-invalid ng-star-inserted" required="">
<div class="date-picker-container"><vsp-form-group>
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input type="text" name="date" ngbdatepicker="" maxlength="10" outsidedays="collapsed" placeholder="DOB" id="birth-date-datepicker" class="form-control ng-untouched ng-pristine ng-invalid" required=""><!----><vsp-tool-tip
label="Tooltip" class="date-picker-tooltip">
<div form-group-icon="">
<!----><i role="button" container="body" class="icon-tooltip d-none d-md-block" tabindex="0" aria-label="Tooltip"></i><!----><i role="button" triggers="click:blur" container="body" class="icon-tooltip d-md-none" tabindex="0" aria-label="Tooltip"></i><!---->
</div>
</vsp-tool-tip></div><label class="vsp-form-group-label" id="birth-date-datepicker-label" for="birth-date-datepicker"> DOB </label><!---->
<div form-group-icon=""><a role="button" aria-label="Toggle Calendar" aria-selected="true" aria-current="true" class="icon-calendar" href=""></a></div><vsp-validation-message id="birth-date-datepicker-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
</vsp-date-picker><!----></div><!---->
</vsp-contact-us-member-info>
<div class="row-line-separator ng-star-inserted"></div><!----><vsp-ssn-and-member-id class="ng-untouched ng-pristine ng-valid ng-star-inserted">
<fieldset><!---->
<div ngmodelgroup="ssnOrMemberIdGroup" class="row ng-untouched ng-pristine ng-invalid"><vsp-form-group label="Last 4 of SSN" class="col-md-3">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="ssn" name="ssn" required="" vspvalidatenumbersonly="" maxlength="4" minlength="4" placeholder="Last 4 of SSN" class="form-control ng-untouched ng-pristine ng-invalid"><!----></div><label class="vsp-form-group-label"
id="ssn-label" for="ssn"> Last 4 of SSN </label><!----><vsp-validation-message id="ssn-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group>
<div class="create-account-input or-label">OR</div><vsp-form-group label="Member ID" class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-id" required="" name="memberId" vspvalidatealphanumericonly="" maxlength="30" placeholder="Member ID" class="form-control ng-untouched ng-pristine ng-invalid"><!----></div><label class="vsp-form-group-label"
id="member-id-label" for="member-id"> Member ID </label><!----><vsp-validation-message id="member-id-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group>
</div><vsp-validation-message class="d-block create-account-ssn-member-validation-message ng-star-inserted"><!----></vsp-validation-message><!----><!---->
</fieldset>
</vsp-ssn-and-member-id><!---->
</fieldset>
</div>
<div class="vsp-form"><vsp-contact-us-patient-info class="ng-untouched ng-pristine ng-valid">
<fieldset class="ng-star-inserted">
<div class="d-md-flex justify-content-start">
<legend class="form-section-header composite-legend">Patient Information</legend>
<div class="checkbox-header-wrapper"><vsp-checkbox-wrapper label="Same as primary member">
<div class="form-check form-check-checkbox"><input type="checkbox" id="sameAsPrimaryMember" name="sameAsPrimaryMember" class="ng-untouched ng-pristine ng-valid form-check-input"><label class="form-check-label"
for="sameAsPrimaryMember">Same as primary member</label></div><!---->
</vsp-checkbox-wrapper></div>
</div>
<div class="row"><vsp-form-group label="Patient First Name" content-before="" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="patient-first-name" name="patientFirstName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Patient First Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label
class="vsp-form-group-label" id="patient-first-name-label" for="patient-first-name"> Patient First Name </label><!----><vsp-validation-message id="patient-first-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----><vsp-form-group label="Patient Last Name" content-before="" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="patient-last-name" name="patientLastName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Patient Last Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label
class="vsp-form-group-label" id="patient-last-name-label" for="patient-last-name"> Patient Last Name </label><!----><vsp-validation-message id="patient-last-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----></div>
<div class="row-line-separator"></div><vsp-address labelprefix="Patient" name="patientAddress" class="d-block mb-3 ng-untouched ng-pristine ng-invalid" required="">
<div class="row"><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="address" vspvalidateaddresscitytext="" placeholder="Patient Address" id="patientaddress-address" class="form-control ng-untouched ng-pristine ng-invalid" required="" maxlength="65"></div><label
class="vsp-form-group-label" id="patientaddress-address-label" for="patientaddress-address"> Patient Address </label><!----><vsp-validation-message id="patientaddress-address-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="city" vspvalidateaddresscitytext="" placeholder="Patient City" id="patientaddress-city" class="form-control ng-untouched ng-pristine ng-invalid" required="" maxlength="65"></div><label class="vsp-form-group-label"
id="patientaddress-city-label" for="patientaddress-city"> Patient City </label><!----><vsp-validation-message id="patientaddress-city-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><ng-select role="listbox" aria-label="Patient State" name="state" bindvalue="value" id="patientaddress-state" class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid"
required="">
<div class="ng-select-container">
<div class="ng-value-container">
<div class="ng-placeholder">Patient State</div><!----><!---->
<div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="off" id="patientaddress-state-ng-select-filter-input" aria-expanded="false"></div>
</div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
</div><!---->
</ng-select></div><label class="vsp-form-group-label" id="patientaddress-state-label" for="patientaddress-state-ng-select-filter-input"> Patient State </label><!----><vsp-validation-message id="patientaddress-state-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="zip" vspvalidatezip="" placeholder="Patient Zip Code" id="patientaddress-zip-code" maxlength="5" class="form-control ng-untouched ng-pristine ng-invalid" required=""></div><label class="vsp-form-group-label"
id="patientaddress-zip-code-label" for="patientaddress-zip-code"> Patient Zip Code </label><!----><vsp-validation-message id="patientaddress-zip-code-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
</vsp-address>
<div class="row">
<div class="col-md-12"><vsp-radio-button-group ngmodelgroup="authorizedRepresentative" messages="Authorized Representative status is required." class="ng-untouched ng-pristine ng-invalid">
<div class="radio-button-group radio-button-group-inline">
<div class="radio-button-group-contents"><label class="radio-button-group-label ng-star-inserted">Are you an <a href="https://cdn.vsp.com/dam/jcr:72bfe9e6-6d66-4e1a-b5a5-6083b5de17ef">authorized representative</a> for this
patient?</label><!---->
<div class="radio-button-group-content d-flex justify-content-start"><vsp-radio-button-wrapper label="Yes">
<div class="form-check form-check-radio"><input required="" type="radio" name="authorizedRepresentativeValue" id="radio-is-authorized-representative-yes" class="ng-untouched ng-pristine form-check-input ng-invalid"><label
class="form-check-label" for="radio-is-authorized-representative-yes">Yes</label></div>
</vsp-radio-button-wrapper><vsp-radio-button-wrapper label="No">
<div class="form-check form-check-radio"><input required="" type="radio" name="authorizedRepresentativeValue" id="radio-is-authorized-representative-no" class="ng-untouched ng-pristine form-check-input ng-invalid"><label
class="form-check-label" for="radio-is-authorized-representative-no">No</label></div>
</vsp-radio-button-wrapper><!----></div>
</div><!---->
</div>
</vsp-radio-button-group></div>
</div>
<div class="row"><vsp-form-group label="Sender First Name" class="col-md-4">
<div class="form-group vsp-form-group disabled form-group-animation-empty">
<div><input id="sender-first-name" name="senderFirstName" minlength="1" maxlength="65" required="" vspvalidatestandardtext="" placeholder="Sender First Name" class="form-control ng-untouched ng-pristine" disabled=""></div><label
class="vsp-form-group-label" id="sender-first-name-label" for="sender-first-name"> Sender First Name </label><!----><vsp-validation-message id="sender-first-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Sender Last Name" class="col-md-4">
<div class="form-group vsp-form-group disabled form-group-animation-empty">
<div><input id="sender-last-name" name="senderLastName" minlength="1" maxlength="65" required="" vspvalidatestandardtext="" placeholder="Sender Last Name" class="form-control ng-untouched ng-pristine" disabled=""></div><label
class="vsp-form-group-label" id="sender-last-name-label" for="sender-last-name"> Sender Last Name </label><!----><vsp-validation-message id="sender-last-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----></div>
</fieldset><!---->
</vsp-contact-us-patient-info></div>
<div class="vsp-form">
<fieldset>
<legend class="form-section-header">Comments</legend><vsp-contact-us-comments name="comments" required="" class="ng-untouched ng-dirty ng-invalid"><vsp-form-group>
<div class="form-group vsp-form-group form-group-animation-empty">
<div><textarea name="comments" vspautoresize="" rows="8" class="form-control form-control-text-area ng-untouched ng-pristine ng-invalid" id="comment-input" placeholder="Enter comment here..." maxlength="2000" required=""
style="height: 185px;"></textarea><vsp-tool-tip aria-label="comments tooltip button" class="comments-tooltip ng-star-inserted">
<div form-group-icon="">
<!----><i role="button" container="body" class="icon-tooltip d-none d-md-block" tabindex="0" aria-label="Comments may only include the following: alphanumeric characters, upper and lower case, period, comma, question mark, colon, semicolon, dash, exclamation, dollar sign, single quote, at symbol, hash, percent, ampersand and parentheses."></i><!----><i role="button" triggers="click:blur" container="body" class="icon-tooltip d-md-none" tabindex="0" aria-label="Comments may only include the following: alphanumeric characters, upper and lower case, period, comma, question mark, colon, semicolon, dash, exclamation, dollar sign, single quote, at symbol, hash, percent, ampersand and parentheses."></i><!---->
</div>
</vsp-tool-tip><!----></div><label class="vsp-form-group-label" id="comment-input-label" for="comment-input"> Enter comment here... </label><!---->
<div form-group-before-validation-text="" class="remaining-text">Remaining: 2000 Characters</div><vsp-validation-message id="comment-input-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></vsp-contact-us-comments>
</fieldset>
</div><vsp-re-captcha class="ng-star-inserted">
<div id="recaptcha" data-callback="handleReCaptchaSubmit" data-size="invisible" class="g-recaptcha" data-sitekey="6Ldgje4aAAAAAFj7m3Yo68-WqbGpug1i728iHeak">
<div class="grecaptcha-badge" data-style="bottomright"
style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Ldgje4aAAAAAFj7m3Yo68-WqbGpug1i728iHeak&co=aHR0cHM6Ly93d3cudnNwLmNvbTo0NDM.&hl=de&v=85AXn53af-oJBEtL2o2WpAjZ&size=invisible&cb=afcj7jxf2yqb" width="256"
height="60" role="presentation" name="a-ti78xrbthbcf" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</vsp-re-captcha><!---->
<div class="d-flex justify-content-end mt-40"><button type="submit" vspvalidationmessagetrigger="" class="btn btn-primary btn-extra-padding button-loader">Submit</button></div>
</form>Text Content
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