clearinghouse2.srsacquiom.com Open in urlscan Pro
207.97.212.119  Public Scan

Form analysis
1 forms found in the DOM

Name: login — POST

<form id="login" method="post" class="small_form" name="login" data-parsley-validate="" novalidate="">
  <input type="hidden" name="_token" value="xjUHk8DTD2U5mhIDtcOItUo0KGa6tfF9ImjMxMEZ">
  <ul>
    <li>
      <label class="data-label">Email:</label>
      <input id="login_email" type="email" name="email" placeholder="Email" value="" data-parsley-trigger="change" data-parsley-error-message="Please enter a valid email" required="">
    </li>
    <li>
      <label class="data-label">Password:</label>
      <input id="login_password" type="password" name="password" placeholder="Password" data-parsley-error-message="Please enter your password" autocomplete="off" required="">
    </li>
    <li>
      <p class="input" id="terms_check">
        <input type="checkbox" name="agree_to_terms" id="agree_to_terms" data-parsley-error-message="Please indicate that you accept the Terms and Conditions and Privacy Policy." required="" data-parsley-multiple="agree_to_terms">
        <label for="agree_to_terms" class="data-label prominent" style="padding-top: 0; margin-left: 7px; display: inline;">I Accept the Acquiom Clearinghouse
          <a href="/pdf/TermsOfUseClearinghouse.pdf" target="_blank">Terms and Conditions and Privacy Policy</a>.</label>
      </p>
      <button id="login_button" class="button_normal" name="login_button" type="submit">Sign In </button>
    </li>
    <li>
      <span class="error_msg"></span>
    </li>
  </ul>
  <div id="forgot_password">
    <a href="/password/email">Forgot Password?</a>
  </div>
</form>

Text Content

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WELCOME!

PLEASE SIGN-IN TO ACCESS YOUR SRS ACQUIOM CLEARINGHOUSE ACCOUNT


 * Email:
 * Password:

 * I Accept the Acquiom Clearinghouse Terms and Conditions and Privacy Policy.
   
   Sign In
 * 

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