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stag-pmp.opifiny.com Open in urlscan Pro
15.156.225.227  Public Scan

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Submitted URL: https://stag-pmp.opifiny.com/
Effective URL: https://stag-pmp.opifiny.com/Login?ReturnUrl=%2F
Submission: On August 18 via manual from IN — Scanned from CA

Form analysis 1 forms found in the DOM

<form id="PMP_LOGIN" autocomplete="off" data-testid="smartform-PMP_LOGIN">
  <div class="transition-base right">
    <div class="one-column ">
      <div class="page page-1">
        <div></div>
        <div class="body row">
          <div class="body-container col-sm-12">
            <div class="elements-container smartforms-elements-container">
              <div elementid="LastName" class="sf-shorttext  form-group mb-3 font-size-14 ">
                <div class="label-container">
                  <div class="input-label lbl_LastName"><label for="LastName" class="input-label-text">Last Name<span class="mandatory"> *</span></label></div>
                </div>
                <div class="input-container "><input type="text" autocomplete="LastName" class="form-control" name="LastName" id="LastName" placeholder="" value=""></div>
              </div>
              <div elementid="ReferenceId" class="sf-shorttext  form-group mb-3 font-size-14 ">
                <div class="label-container">
                  <div class="input-label lbl_ReferenceId"><label for="ReferenceId" class="input-label-text">Claim ID<span class="mandatory"> *</span></label></div>
                </div>
                <div class="input-container "><input type="text" autocomplete="ReferenceId" class="form-control" name="ReferenceId" maxlength="100" id="ReferenceId" placeholder="" value=""></div>
              </div>
              <div elementid="PostalCode" class="sf-shorttext  form-group font-size-14 ">
                <div class="label-container">
                  <div class="input-label lbl_PostalCode"><label for="PostalCode" class="input-label-text">Postal Code<span class="mandatory"> *</span></label></div>
                </div>
                <div class="input-container "><input type="text" autocomplete="PostalCode" class="form-control" name="PostalCode" id="PostalCode" placeholder="" value=""></div>
              </div>
              <div></div>
              <div class="button  "><button name="SignIn" class="btn">Submit</button></div>
              <div elementid="ErrorMessage" class="label red errorMessage ">
                <div class="label-container">
                  <div class="label-label lbl_ErrorMessage"></div>
                </div>
              </div>
            </div>
          </div>
        </div>
        <div></div>
      </div>
    </div>
  </div>
</form>

Text Content

SIGN IN

Last Name *

Claim ID *

Postal Code *


Submit


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HELPING INSURANCE PROVIDERS MANAGE THEIR MEDICAL REQUESTS


 * SECURE ACCESS
   
   
   
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   protect your data and personal information.


 * DIGITALLY SIGN CONSENTS
   
   
   
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   sign authorization to have your doctor share your medical information.


 * EASY PAYMENTS
   
   
   
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   credit card


 * ALWAYS IN THE KNOW
   
   
   
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