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secure.arallegiance.com Open in urlscan Pro
66.6.107.128  Public Scan

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Submitted URL: https://billing.homemedix.com/
Effective URL: https://secure.arallegiance.com/CollectPayLive/Public/Home/PatientLogin?A=;%c3%b1%c2%b2
Submission: On September 01 via automatic, source certstream-suspicious — Scanned from CA

Form analysis 2 forms found in the DOM

POST /CollectPayLive/Public/Home/PatientLogin?A=;%c3%b1%c2%b2

<form action="/CollectPayLive/Public/Home/PatientLogin?A=;%c3%b1%c2%b2" method="post" novalidate="novalidate"><input data-val="true" data-val-required="The IsActiveClient field is required." id="IsActiveClient" name="IsActiveClient" type="hidden"
    value="True"><input data-val="true" data-val-required="The IsRegistrationPageRequired field is required." id="IsRegistrationPageRequired" name="IsRegistrationPageRequired" type="hidden" value="True"><input data-val="true"
    data-val-required="The IsUsingPapaya field is required." id="IsUsingPapaya" name="IsUsingPapaya" type="hidden" value="True">
  <div id="dvUserLoginBillPay" class="col-12 col-md-6 bottomdiv position-relative float-start col-md-pull-6">
    <div class="form-horizontal">
      <p class="heading">Full Account Access + Bill Pay</p>
      <div class="form-group flex flex-wrap">
        <div class="col-12 col-md-6 MB20">
          <input autocomplete="off" class="form-control" data-val="true" data-val-length="Maximum characters allowed is 100." data-val-length-max="100" id="txtEmail" maxlength="100" name="Username" placeholder="Username *" type="text" value="">
          <span class="field-validation-valid text-danger" data-valmsg-for="Username" data-valmsg-replace="true" id="txtUsername"></span>
          <a href="/CollectPayLive/Public/Home/PatientForgotUserName">Forgot your Username?</a>
        </div>
        <div class="col-12 col-md-6 MB20">
          <input autocomplete="off" class="form-control" data-val="true" data-val-length="Maximum characters allowed is 25." data-val-length-max="25" id="Password" maxlength="25" name="Password" placeholder="Password *" type="password">
          <span class="field-validation-valid text-danger" data-valmsg-for="Password" data-valmsg-replace="true" id="txtPassword"></span>
          <a href="/CollectPayLive/Public/Home/PatientForgotPassword">Forgot your Password?</a>
        </div>
      </div>
      <div>
        <div id="DivPatientErrorMsg" class="text-center mandatoryfield">
        </div>
      </div>
      <div class="form-group flex flex-wrap">
        <div id="dvSepratorH2"><img src="/CollectPayLive/Public/images/sepratorhorizontal.png"></div>
      </div>
      <div class="form-group">
        <p class="heading"> Quick Bill Pay with your Invoice <br> <span style="font-size: 10pt; vertical-align: text-top ">No account required.</span> </p>
        <div class="form-group flex flex-wrap">
          <div class="col-12 col-lg-6 MB20">
            <input autocomplete="off" class="form-control" data-val="true" data-val-length="Maximum characters allowed is 50." data-val-length-max="50" data-val-regex="Please enter a valid Account Number."
              data-val-regex-pattern="[a-zA-Z0-9_. ,-/:#]*" id="txtAccountNumber" maxlength="50" name="AccountNumber" placeholder="Account Number *" type="text" value="">
            <span class="field-validation-valid text-danger" data-valmsg-for="AccountNumber" data-valmsg-replace="true"></span>
          </div>
          <div class="col-12 col-lg-6">
            <input autocomplete="off" class="form-control" data-val="true" data-val-length="Maximum characters allowed is 50." data-val-length-max="50" data-val-regex="Please enter a valid Invoice Number."
              data-val-regex-pattern="[a-zA-Z0-9_. ,-/:#]*" id="txtInvoiceNumber" maxlength="50" name="InvoiceNumber" placeholder="Invoice Number *" type="text" value="">
            <span class="field-validation-valid text-danger" data-valmsg-for="InvoiceNumber" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
      <div class="clearfix"></div>
      <div class="text-center">
        <div id="DivErrorMsg" style="color: red">
        </div>
      </div>
      <div class="clearfix"></div>
      <div class="text-center">
        <input type="hidden" value="0" id="LoginAttemptNo" name="LoginAttemptNo">
      </div>
      <div class="clearfix"></div>
      <div class="text-center">
        <input id="btnLogin" type="submit" value="Log In" class="btn btn-sm btn-primary  m-t-n-xs">
      </div>
    </div>
  </div>
</form>

POST /CollectPayLive/Public/Home/SetUserName?Length=4

<form action="/CollectPayLive/Public/Home/SetUserName?Length=4" autocomplete="off" data-ajax="true" data-ajax-method="POST" data-ajax-success="SetUserNameSuccess" id="SetUserNameForm" method="post"><input name="__RequestVerificationToken"
    type="hidden" value="oHRXq8BRjjCJLtZ0V7Y_jkMib2YnYKDCYvb3VBpRpah69jYMEu62fXhZPzviFQsnV__k-jAv0z-9M6A1QQt_LwpHtC_rXgbvLQHqaB1mBRc1">
  <div class="overlay">
    <div class="ibox-title">
      <h5> Due to increased security measures, we now require all users to setup a username for their accounts. Please setup a new username now and click the Submit button. </h5>
    </div>
    <div id="UserNameSuccess" style="display:none" class="ibox-content">
      <div class="form-group">
        <p id="UserNameSuccessDiv"></p>
      </div>
    </div>
    <div id="UserNameFields" class="ibox-content">
      <div class="form-group">
        <div>
          <p id="ErrorMessage" style="display:none;color:red"></p>
          <input autocomplete="off" class="form-control" id="txtUserName" maxlength="100" name="txtUserName" type="text" value="">
          <input id="hdnCPLUserId" name="hdnCPLUserId" type="hidden" value="0">
        </div>
      </div>
    </div>
    <div>
      <input id="btnSubmit" type="submit" value="Submit" class="btn btn-sm btn-primary  m-t-n-xs">
      <input id="btnOK" style="display:none" onclick="PopUpCLose()" type="button" value="OK" class="btn btn-sm btn-primary  m-t-n-xs">
    </div>
  </div>
</form>

Text Content

 1. Home Medix

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