h1billing.clanwilliamhealth.com Open in urlscan Pro
2606:4700:4400::6812:262b  Public Scan

Form analysis
1 forms found in the DOM

POST

<form novalidate="" class="form email-form contents form-labels-inside" method="post" data-id="element-302" data-at="form" action-xhr="https://d.fastcdn.co/submissions">
  <input id="field-68b5897f5e884e702dbcf5c14839f42b-0" class="form-input form-input-text required  " data-at="form-text" type="text" name="Contact Name" data-describedby="form-validation-error-box-element-302" value="" title="Contact Name"
    placeholder="Contact Name" data-label-inside="Contact Name" required="" aria-required="true">
  <input id="field-68b5897f5e884e702dbcf5c14839f42b-1" class="form-input form-input-text required  " data-at="form-text" type="text" name="Practice Name" data-describedby="form-validation-error-box-element-302" value="" title="Practice Name"
    placeholder="Practice Name" data-label-inside="Practice Name" required="" aria-required="true">
  <input id="field-68b5897f5e884e702dbcf5c14839f42b-2" class="form-input form-input-text required  " data-at="form-text" type="text" name="Health One Account Number" data-describedby="form-validation-error-box-element-302" value=""
    title="Health One Account Number" placeholder="Health One Account Number" data-label-inside="Health One Account Number" required="" aria-required="true">
  <input id="field-68b5897f5e884e702dbcf5c14839f42b-3" class="form-input form-input-text required  " data-at="form-text" type="text" name="Contact Number" data-describedby="form-validation-error-box-element-302" value="" title="Contact Number"
    placeholder="Contact Number" data-label-inside="Contact Number" required="" aria-required="true">
  <input id="field-68b5897f5e884e702dbcf5c14839f42b-4" class="form-input form-input-text required  " type="email" name="Email Address" data-describedby="form-validation-error-box-element-302" value="" title="Email Address"
    data-label-inside="Email Address" data-at="form-email" placeholder="Email Address" required="" aria-required="true">
  <input type="hidden" name="lpsSubmissionConfig"
    value="eyJhbGciOiJIUzI1NiJ9.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.9wMttPKFTi4OTm7vXGwkcLFzmDhFlgZOZRnnYw_D7SE"
    data-at="form-hidden-input">
  <input type="hidden" name="thank-you-message" value="VGhhbmsgeW91ISBXZSBoYXZlIHJlY2VpdmVkIHlvdXIgc3VibWlzc2lvbiBhbmQgd2Ugd2lsbCBiZSBpbiB0b3VjaCBzb29uIHRvIGdldCB5b3Ugc2V0IHVwIGZvciBCaWxsaW5rLiA=" data-at="form-hidden-input">
  <input type="hidden" name="thank-you-message-timeout" value="3000" data-at="form-hidden-input">
  <div class="item-absolute form-btn-geometry">
    <button class="btn form-btn item-block  " data-at="form-button"> Submit your details </button>
  </div>
</form>

Text Content

MOVING TO THE NEW HEALTH ONE BILLING MODULE




Please enter your details below

Once we receive your details we will make contact as soon as possible to update
your system to the New Billing Module

Submit your details


By filling in this form you are agreeing to be contacted by a member of our team
to discuss your transition to the New Billing Module


Thank You!