emb.patientwallet.com
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65.9.63.28
Public Scan
Submitted URL: https://scpmedbilling.com/
Effective URL: https://emb.patientwallet.com/
Submission: On February 18 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://emb.patientwallet.com/
Submission: On February 18 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 27 forms found in the DOM
Name: forms.createForm —
<form name="forms.createForm" novalidate=""
class="ng-pristine ng-invalid ng-invalid-required ng-valid-email ng-valid-maxlength ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-valid-minlength ng-valid-mismatch ng-valid-sms-eligible">
<div class="split-input-areas-container">
<!-- FIRST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.firstName.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="register-first" active="forms.createForm.firstName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="firstName" type="text" id="register-first" sensitive="" valid-name="" placeholder="First Name" ng-model="register.firstName" tabindex="1"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.firstName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- LAST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.lastName.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="register-last" active="forms.createForm.lastName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="lastName" type="text" id="register-last" sensitive="" valid-name="" placeholder="Last Name" ng-model="register.lastName" tabindex="2"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.lastName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</div>
<!-- EMAIL -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.email.$invalid && (forms.createForm.$submitted || forms.createForm.email.$error.emailAvailable)}">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="register-email" active="forms.createForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input required="" name="email" type="email" sensitive="" valid-email="" email-available="" autocapitalize="off" autocorrect="off" autosuggest="off" id="register-email" placeholder="Email Address"
on-email-check-finished="asyncValidationComplete" ng-model="register.email" tabindex="3" maxlength="255" ng-model-options="{ updateOn: 'blur submit' }"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<!-- ngIf: forms.createForm.email.$invalid && (forms.createForm.$submitted || forms.createForm.email.$error.emailAvailable) -->
</div>
</div>
<!-- PHONE -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.phone.$invalid && forms.createForm.phone.$touched}">
<div class="input-area-field-wrapper">
<icon name="phone" size="md" for="details-phone" active="forms.createForm.phone.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" version="1.1" focusable="false" x="0px" y="0px"
viewBox="0 0 51 51.3" enable-background="new 0 0 51 51.3" xml:space="preserve" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/phone-md.svg">
<path fill="#939598"
d="M1.9,13c0,0,1.1-5.3,4-8.8l3-2.2c0,0,3.4-0.8,7,4.6s2.5,7.7,2.5,7.7L15.2,18c0,0,0.3,3.4,1.9,5.6 s8.2,9.3,10,10.7c1.8,1.3,3.3,2.1,5.2,2.1l1.3-2.3c0,0,1.1-2,3.6-1.8c2.6,0.3,5.7,1.2,5.7,1.2S49.5,36,49,40l-1.2,3.8 c0,0-3.6,4.3-10.7,5.3c0,0-12.7-6.5-21.5-15.6S1.9,13,1.9,13z">
</path>
</svg></icon>
<input name="phone" type="text" id="create-phone" phone-number="" sms-eligible="" sensitive="" placeholder="Mobile Phone" on-phone-check-finished="asyncValidationComplete" ng-model="register.phoneNumber" tabindex="4"
ng-model-options="{updateOn: 'default blur submit'}" maxlength="12" class="ng-pristine ng-untouched ng-valid input-with-icon ng-isolate-scope fs-block ng-valid-maxlength ng-valid-minlength ng-valid-sms-eligible">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.phone.$error" class="ng-inactive">
<!-- ngMessage: minlength -->
<!-- ngMessage: smsEligible -->
</div>
</div>
</div>
<!-- PASSWORD -->
<div class="input-area-wrapper login-password-input-area" ng-class="{
errored: forms.createForm.password.$invalid && forms.createForm.$submitted,
'login-password-incorect-blurred': forms.createForm.password.$dirty && forms.createForm.password.$invalid
}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="register-pass" active="forms.createForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="password" type="password" valid-password="" id="register-pass" maxlength="255" sensitive="" placeholder="Password" ng-model="register.password" tabindex="5"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-rules">
<ul>
<li ng-class="{'rule-met': !forms.createForm.password.$error.minCharactersRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 8 characters
</li>
<li ng-class="{'rule-met': !forms.createForm.password.$error.upperCaseRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 uppercase letter
</li>
<li ng-class="{'rule-met': !forms.createForm.password.$error.digitRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 number
</li>
</ul>
</div>
</div>
<!-- CONFIRM PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.password.$valid && forms.createForm.confirmPassword.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="register-con-pass" active="forms.createForm.confirmPassword.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="confirmPassword" type="password" id="register-con-pass" match="register.password" valid-password="" sensitive="" placeholder="Confirm Password" ng-model="register.confirmPassword" tabindex="6"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-mismatch">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.confirmPassword.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: mismatch -->
</div>
</div>
</div>
<div class="register-checkboxes">
<!-- SMS OPT-IN -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.receivesSms.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper no-initial-border inline-input-type">
<input id="receivesSms" name="receivesSms" type="checkbox" ng-model="register.receivesSms" tabindex="7" class="ng-pristine ng-untouched ng-valid">
<label for="receivesSms" class="create-account-terms" compile="'labels.receivesSms' | translate"><span class="ng-scope">Text me new bills & reminders</span></label>
</div>
</div>
<!-- TERMS OF USE -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.tou.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper no-initial-border inline-input-type">
<input required="" id="tou" name="tou" type="checkbox" ng-model="register.acceptTerms" tabindex="8" class="ng-pristine ng-untouched ng-invalid ng-invalid-required">
<label for="tou" class="create-account-terms" compile="'labels.acceptanceOfTerms' | translate"><span class="ng-scope">I agree to the
</span><a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank" class="ng-scope">Terms of Use</a></label>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.tou.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> For legal reasons, we require all users to accept our Terms of Use. </div>
</div>
</div>
</div>
</div>
<button class="button button-primary ng-binding" ng-click="submitRegister();" tabindex="8">Create Account</button>
<!-- ngIf: showPayAsGuestOption -->
<div ng-messages="submissionNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: guestPayErrored -->
</div>
</form>Name: forms.loginForm —
<form name="forms.loginForm" novalidate="" class="ng-pristine ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
<!-- FORM SUBMISSION RESPONSE FEEDBACK -->
<div ng-messages="submissionNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: loginFailed -->
<!-- ngMessage: userBlocked -->
<!-- ngMessage: resetPasswordComplete -->
</div>
<!-- EMAIL -->
<div class="input-area-wrapper" ng-class="{errored: forms.loginForm.email.$invalid && forms.loginForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="login-email" active="forms.loginForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input sensitive="" name="email" type="email" required="" valid-email="" id="login-email" ng-model="login.email" autocapitalize="off" maxlength="255" placeholder="Email Address"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.loginForm.email.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please enter an email address to help us find your account. </div>
<!-- ngMessage: email -->
</div>
</div>
</div>
<!-- PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: forms.loginForm.password.$invalid && forms.loginForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="login-pass" active="forms.loginForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input sensitive="" name="password" type="password" required="" id="login-pass" placeholder="Password" ng-model="login.password" class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.loginForm.password.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-scope">
<div ng-bind-html="(subdomain ? 'whitelabel.' : '') + 'errors.loginPasswordRequired' | translate" class="ng-binding">Please enter your account password to log in to PatientWallet.</div>
</div>
</div>
</div>
</div>
<button class="button button-primary ng-binding" ng-click="submitLogin();">Log In</button>
<button class="button button-secondary ng-binding" ng-click="toggleForgotPassword();" ng-bind="'actions.forgotPassword' | translate">Forgot Your Password?</button>
</form>Name: forms.forgotForm —
<form name="forms.forgotForm" novalidate="" class="ng-pristine ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
<!-- EMAIL -->
<div class="input-area-wrapper forgot-email-input" ng-class="{ errored: forms.forgotForm.email.$invalid && forms.forgotForm.$submitted }">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="forgot-email" active="forms.forgotForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input sensitive="" name="email" type="email" required="" maxlength="255" id="forgot-email" ng-model="forgotPassword.email" autocapitalize="off" valid-email="" on-email-check-finished="emailRegisteredCheckFinished"
ng-model-options="{ updateOn: 'blur submit' }" placeholder="Email Address" class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.forgotForm.email.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: email -->
<!-- ngMessage: emailAvailable -->
</div>
</div>
</div>
<button class="button button-primary ng-binding" ng-click="submitForgot();" ng-bind="(retrieving ? 'actions.retrievingResetOptions' : 'login.nextButton') | translate">Next</button>
</form>Name: forms.methodForm —
<form name="forms.methodForm" novalidate="" class="ng-pristine ng-valid">
<div class="contact-method">
<button sensitive="" class="button button-primary button-block u-truncate ng-binding fs-block ng-hide" ng-show="forgotPassword.hasVerifiedEmail" ng-disabled="sendingForgotPassword" ng-click="submitForgotMethod('email');"
ng-bind="'login.forgotPasswordMethodEmailButton' | translate: {email: forgotPassword.email}">Email me ()</button>
<button sensitive="" class="button button-primary button-block ng-binding fs-block ng-hide" ng-show="forgotPassword.smsAvailable" ng-click="submitForgotMethod('sms');" ng-disabled="sendingForgotPassword"
ng-bind="'login.forgotPasswordMethodSmsButton' | translate: {phone: forgotPassword.maskedPhone}">Text me ()</button>
</div>
</form>Name: forms.verifyForm —
<form name="forms.verifyForm" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength">
<div class="input-area-wrapper" ng-class="{errored: (forms.verifyForm.code.$error.required || forms.verifyForm.code.$error.maxlength) && forms.verifyForm.$submitted}">
<div class="input-area-field-wrapper">
<input name="code" type="text" all-numeric="" required="" placeholder="Verification Code" ng-model="forgotPassword.code" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}" maxlength="6" autocomplete="off"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyForm.code.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<div class="modal-actions ng-isolate-scope"><ng-transclude>
<button type="button" class="button button-secondary ng-binding ng-scope" ng-click="sendAgain();" ng-bind="'login.forgotPasswordMethodSendAgainButton' | translate">I didn't receive a code</button>
<button class="button button-primary ng-binding ng-scope" ng-click="submitForgotVerify();" ng-bind="'login.nextButton' | translate">Next</button>
</ng-transclude></div>
</form>Name: forms.resetPasswordForm —
<form name="forms.resetPasswordForm" novalidate="" class="ng-pristine ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength ng-valid-mismatch">
<!-- FORM SUBMISSION RESPONSE FEEDBACK -->
<div ng-messages="resetNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: invalidAttempt -->
</div>
<!-- PASSWORD -->
<div class="input-area-wrapper login-password-input-area" ng-class="{
errored: forms.resetPasswordForm.password.$invalid && forms.resetPasswordForm.$submitted,
'login-password-incorect-blurred': forms.resetPasswordForm.password.$dirty && forms.resetPasswordForm.password.$invalid
}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="reset-pass" active="forms.resetPasswordForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="password" type="password" valid-password="" id="reset-pass" maxlength="255" sensitive="" placeholder="New Password" ng-model="resetPassword.password" tabindex="2"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-rules">
<ul>
<li ng-class="{'rule-met': !forms.resetPasswordForm.password.$error.minCharactersRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 8 characters
</li>
<li ng-class="{'rule-met': !forms.resetPasswordForm.password.$error.upperCaseRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 uppercase letter
</li>
<li ng-class="{'rule-met': !forms.resetPasswordForm.password.$error.digitRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 number
</li>
</ul>
</div>
</div>
<!-- CONFIRM PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: forms.resetPasswordForm.password.$valid && forms.resetPasswordForm.confirmPassword.$invalid && forms.resetPasswordForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="reset-con-pass" active="forms.resetPasswordForm.confirmPassword.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="confirmPassword" type="password" id="reset-con-pass" match="resetPassword.password" valid-password="" sensitive="" placeholder="Confirm Password" ng-model="resetPassword.confirmPassword" tabindex="3"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-mismatch">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.resetPasswordForm.confirmPassword.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: mismatch -->
</div>
</div>
</div>
<button class="button button-primary ng-binding" tabindex="4" ng-click="submitReset();" ng-bind="resetDialog">Reset Password</button>
</form>Name: forms.composeForm —
<form novalidate="novalidate" name="forms.composeForm" class="v-form">
<div class="form-title">New Message</div>
<div>
<div>
<div data-testid="compose-message-provider-list">
<div class="vuetify compose-options-listing">
<div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-8" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-8" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Provider</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-8" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div data-testid="compose-message-account-list">
<div class="vuetify compose-options-listing">
<div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-12" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-12" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select an Account</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-12" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-testid="compose-message-reasons-list">
<div class="v-input v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-15" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-15" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Reason</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-15" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden" value="[object Object]">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
<div>
<div
class="v-input vuetify compose-message-textarea v-textarea v-textarea--auto-grow v-textarea--no-resize v-input--hide-details theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-text-field--placeholder">
<div class="v-input__control">
<div class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span></span></legend>
</fieldset>
<div class="v-text-field__slot"><label for="input-18" class="v-label theme--light" style="left: 0px; right: auto; position: absolute;">Message</label><textarea name="message" required="required" maxlength="5000" id="input-18" rows="5"
style="height: 125px;"></textarea></div>
</div>
</div>
</div>
</div>
<div class="" style="display: none;">
<div class="vuetify keep-right attachment-button"><button type="button" class="button-secondary vuetify no-capitalization v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-attach-button" style="display: none;"><span
class="v-btn__content">Attach a file <span aria-hidden="true" class="v-icon notranslate v-icon--right theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true" class="v-icon__svg">
<path
d="M7.5,18A5.5,5.5 0 0,1 2,12.5A5.5,5.5 0 0,1 7.5,7H18A4,4 0 0,1 22,11A4,4 0 0,1 18,15H9.5A2.5,2.5 0 0,1 7,12.5A2.5,2.5 0 0,1 9.5,10H17V11.5H9.5A1,1 0 0,0 8.5,12.5A1,1 0 0,0 9.5,13.5H18A2.5,2.5 0 0,0 20.5,11A2.5,2.5 0 0,0 18,8.5H7.5A4,4 0 0,0 3.5,12.5A4,4 0 0,0 7.5,16.5H17V18H7.5Z">
</path>
</svg></span></span></button></div> <input type="file" focus="0" accept=".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.txt" multiple="multiple" class="fs-block" style="display: none;">
<div style="display: none;">
<div data-testid="compose-message-message-attachments" class="message-attachments fs-block"></div>
</div> <!---->
</div>
<div class="vuetify keep-right form-buttons"><button type="button" class="button-bigger-text vuetify v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-cancel-button"><span class="v-btn__content">Cancel</span></button>
<button type="button" disabled="disabled" class="button-bigger-text vuetify v-button-primary v-btn v-btn--disabled v-btn--has-bg theme--light v-size--default" data-testid="compose-message-send-button"><span
class="v-btn__content">SEND</span></button></div>
</form>Name: forms.scEmailForm —
<form name="forms.scEmailForm" ng-submit="submitVerify()" novalidate="" class="ng-pristine ng-scope ng-valid-min ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
<!-- FORM SUBMISSION RESPONSE FEEDBACK -->
<div ng-messages="searchErrors" class="interaction-feedback ng-inactive">
<!-- ngMessage: notFound -->
<!-- ngMessage: throttled -->
</div>
<!-- EMAIL -->
<div class="modal-text ng-binding" ng-hide="isLoggedIn && contact.email">Please enter your email address:</div>
<div class="input-area-wrapper" ng-class="{errored: forms.scEmailForm.email.$invalid && forms.scEmailForm.$submitted}" ng-hide="isLoggedIn && contact.email">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="contact-bill-email" active="forms.scEmailForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input required="" name="email" type="email" sensitive="" valid-email="" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-bill-email" placeholder="Email Address" ng-model="contact.email" tabindex="1" maxlength="255"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<!-- ngIf: forms.scEmailForm.email.$invalid && forms.scEmailForm.$submitted -->
</div>
</div>
<div class="modal-text ng-binding"> Please enter your bill details:</div>
<!-- SECURECODE -->
<div class="input-area-wrapper" ng-class="{errored: forms.scEmailForm.scode.$invalid && (forms.scEmailForm.scode.$dirty || forms.scEmailForm.$submitted)}">
<div class="input-area-field-wrapper">
<icon name="bill-scode" for="contact-bill-scode" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" version="1.1" focusable="false" x="0px" y="0px" viewBox="0 0 36.5 36.5"
enable-background="new 0 0 36.5 36.5" xml:space="preserve" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/bill-scode-md.svg">
<circle fill="#08A650" cx="18.2" cy="18.3" r="18"></circle>
<g>
<path fill="#FFFFFF" d="M23.5,17.2l-11.7,0c0,1.8-0.1,4.1-0.2,6c-0.2,4.4,3.5,6.7,7.1,6.5c4.2-0.2,5-4.7,5-4.7S23.5,20.6,23.5,17.2 "></path>
<path fill="#FFFFFF" d="M17.9,11.3l-5.1-0.1c-0.9,0.3-1,2-1,2s0,1.1,0,2.8l6.2,0L17.9,11.3z"></path>
<path fill="#FFFFFF" d="M23.5,16c0-1,0-1.8,0.1-2.2c0.2-1.9-1.4-2.4-1.4-2.4l-3,0c0,1.7,0.1,4,0.1,4.7L23.5,16z"></path>
<path fill="none" stroke="#FFFFFF" stroke-width="1.4236" stroke-miterlimit="10" d="M17.8,10.7C17.6,6,23.1,6,23.1,6"></path>
</g>
</svg></icon>
<input sensitive="" ng-model="contact.secureCode" type="text" required="" id="contact-bill-scode" tabindex="2" securecode-input="" name="scode" autocomplete="off" ng-model-options="{ debounce: 100 }" placeholder="SecureHealthCode on Bill"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required" maxlength="11">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.scEmailForm.scode.$error" ng-show="forms.scEmailForm.$dirty || forms.scEmailForm.$submitted" class="ng-hide ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-scope">
<div ng-bind-html="transworld ? 'transworld.clientRefNumRequired' : ((subdomain ? 'whitelabel.' : '') + 'errors.scodeRequired') | translate" class="ng-binding">Please enter the SecureHealthCode located in the top right section of your bill.
</div>
</div>
<!-- ngMessage: allNumericSCode -->
</div>
</div>
</div>
<!-- AMOUNT -->
<div class="input-area-wrapper" autocomplete="off" ng-class="{errored: (forms.scEmailForm.billAmount.$error.required || forms.scEmailForm.billAmount.$error.min) && (forms.scEmailForm.billAmount.$dirty || forms.scEmailForm.$submitted)}">
<div class="input-area-field-wrapper">
<icon name="bill-amount" for="contact-bill-amount" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" version="1.1" focusable="false" x="0px" y="0px" viewBox="0 0 36.5 20.5"
enable-background="new 0 0 36.5 20.5" xml:space="preserve" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/bill-amount-md.svg">
<path fill="#10356B" d="M0.6,20.1c-0.2,0.1-0.3-0.1-0.3-0.2V7.5c0-0.1,0.1-0.2,0.2-0.2c1.7-0.7,15.9-6.3,17.7-7c0.1,0,0.2,0,0.3,0 c1.7,0.7,16,6.3,17.7,7c0.1,0,0.2,0.1,0.2,0.2v12.4c0,0.2-0.2,0.3-0.3,0.2l-17.5-6.8c-0.1,0-0.2,0-0.4,0L0.6,20.1z">
</path>
</svg></icon>
<input sensitive="" ng-model="contact.billAmount" currency="" tabindex="3" type="text" id="contact-bill-amount" name="billAmount" required="" min="0" maxlength="20" placeholder="Total Balance Due on Bill"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-min ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.scEmailForm.billAmount.$error" ng-show="forms.scEmailForm.$dirty || forms.scEmailForm.$submitted" class="ng-hide ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please enter the total balance printed on your bill. We'll ask for your desired payment amount in the next step. </div>
<!-- ngMessage: min -->
</div>
</div>
</div>
<button class="button-primary ng-binding" tabindex="4" ng-bind="verifyDialog">Verify</button>
<button type="button" tabindex="5" class="button ng-binding" ng-bind="back" ng-click="goPrevious();">Back</button>
</form>Name: forms.createForm —
<form name="forms.createForm" novalidate="" class="ng-pristine ng-scope ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength ng-valid-mismatch">
<h2 class="modal-header ng-binding">Almost there...</h2>
<div class="modal-text ng-binding">Please create a password:</div>
<!-- PASSWORD -->
<div class="input-area-wrapper login-password-input-area" ng-class="{
errored: forms.createForm.password.$invalid && forms.createForm.$submitted,
'login-password-incorect-blurred': forms.createForm.password.$dirty && forms.createForm.password.$invalid
}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="contact-register-pass" active="forms.createForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="password" type="password" valid-password="" id="contact-register-pass" maxlength="255" sensitive="" placeholder="Password" ng-model="contact.password" tabindex="4"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-rules">
<ul>
<li ng-class="{'rule-met': !forms.createForm.password.$error.minCharactersRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 8 characters
</li>
<li ng-class="{'rule-met': !forms.createForm.password.$error.upperCaseRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 uppercase letter
</li>
<li ng-class="{'rule-met': !forms.createForm.password.$error.digitRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 number
</li>
</ul>
</div>
</div>
<!-- CONFIRM PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.password.$valid && forms.createForm.confirmPassword.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="contact-register-con-pass" active="forms.createForm.confirmPassword.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="confirmPassword" type="password" id="contact-register-con-pass" match="contact.password" valid-password="" sensitive="" placeholder="Confirm Password" ng-model="contact.confirmPassword" tabindex="5"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-mismatch">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.confirmPassword.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: mismatch -->
</div>
</div>
</div>
<!-- TERMS OF USE -->
<div class="input-area-wrapper" ng-class="{errored: forms.createForm.tou.$invalid && forms.createForm.$submitted}">
<div class="input-area-field-wrapper no-initial-border">
<input required="" name="tou" id="contact-tou" type="checkbox" ng-model="contact.acceptTerms" tabindex="6" class="ng-pristine ng-untouched ng-invalid ng-invalid-required">
<label for="contact-tou" class="create-account-terms" compile="'labels.acceptanceOfTerms' | translate"><span class="ng-scope">I agree to the
</span><a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank" class="ng-scope">Terms of Use</a></label>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.createForm.tou.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> For legal reasons, we require all users to accept our Terms of Use. </div>
</div>
</div>
</div>
<button tabindex="7" class="button button-primary ng-binding" ng-bind="submitDialog" ng-click="submitRegister();">Submit</button>
<button tabindex="8" type="button" class="button ng-binding" ng-bind="back" ng-click="goPrevious();">Back</button>
</form>Name: forms.loginForm —
<form name="forms.loginForm" novalidate="" class="ng-pristine ng-scope ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
<h2 class="modal-header ng-binding">Almost there...</h2>
<!-- FORM SUBMISSION RESPONSE FEEDBACK -->
<div ng-messages="submissionNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: loginFailed -->
<!-- ngMessage: userBlocked -->
<!-- ngMessage: resetPasswordComplete -->
</div>
<!-- EMAIL -->
<div class="modal-text ng-binding"> Please log in to your account: </div>
<div class="input-area-wrapper" ng-class="{errored: forms.loginForm.email.$invalid && forms.loginForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="contact-login-email" active="forms.loginForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input tabindex="1" sensitive="" name="email" type="email" required="" valid-email="" ng-model="contact.email" autocapitalize="off" maxlength="255" placeholder="Email Address" id="contact-login-email"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.loginForm.email.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please enter an email address to help us find your account. </div>
<!-- ngMessage: email -->
</div>
</div>
</div>
<!-- PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: forms.loginForm.password.$invalid && forms.loginForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="contact-login-pass" active="forms.loginForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input id="contact-login-pass" tabindex="2" sensitive="" name="password" type="password" required="" placeholder="Password" ng-model="contact.password" class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.loginForm.password.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-scope">
<div ng-bind-html="(subdomain ? 'whitelabel.' : '') + 'errors.loginPasswordRequired' | translate" class="ng-binding">Please enter your account password to log in to PatientWallet.</div>
</div>
</div>
</div>
</div>
<div class="login-forgot-password-link">
<a href="" ng-bind="'actions.forgotPassword' | translate" ng-click="forgot()" tabindex="3" class="ng-binding">Forgot Your Password?</a>
</div>
<button tabindex="4" class="button button-primary ng-binding" ng-bind="submitDialog" ng-click="submitLogin();">Submit</button>
<button tabindex="5" type="button" class="button ng-binding" ng-bind="back" ng-click="goPrevious();">Back</button>
</form>Name: forms.contactForm —
<form name="forms.contactForm" ng-submit="sendZenMessage()" novalidate="" class="ng-pristine ng-scope ng-invalid ng-invalid-required ng-valid-email ng-valid-maxlength">
<div class="split-input-areas-container" ng-hide="isLoggedIn && contact.firstName && contact.lastName">
<!-- FIRST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.contactForm.firstName.$invalid && forms.contactForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="contact-zendesk-first" active="forms.contactForm.firstName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="firstName" type="text" id="contact-zendesk-first" sensitive="" valid-name="" placeholder="First Name" ng-model="contact.firstName" tabindex="1"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.contactForm.firstName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- LAST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.contactForm.lastName.$invalid && forms.contactForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="contact-zendesk-last" active="forms.contactForm.lastName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="lastName" type="text" id="contact-zendesk-last" sensitive="" valid-name="" placeholder="Last Name" ng-model="contact.lastName" tabindex="2"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.contactForm.lastName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</div>
<!-- EMAIL -->
<div class="input-area-wrapper" ng-class="{errored: forms.contactForm.email.$invalid && forms.contactForm.$submitted}" ng-hide="isLoggedIn && contact.email">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="contact-zendesk-email" active="forms.contactForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input required="" name="email" type="email" sensitive="" valid-email="" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-zendesk-email" placeholder="Email Address" ng-model="contact.email" tabindex="3" maxlength="255"
ng-model-options="{ updateOn: 'blur submit' }" class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<!-- ngIf: forms.contactForm.email.$invalid && forms.contactForm.$submitted -->
</div>
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.contactForm.message.$invalid && forms.contactForm.$submitted}">
<div class="input-area-field-wrapper no-initial-border">
<textarea sensitive="" required="" maxlength="5000" name="message" placeholder="Start typing your message..." ng-model="contact.message" tabindex="4"
class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-maxlength"> </textarea>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.contactForm.message.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<p class="info ng-binding" ng-bind="'dialogs.phiWarning' | translate">For your security, please exclude personal health information.</p>
<div class="form-error">
<div ng-messages="notifications" class="ng-inactive">
<!-- ngMessage: fiveHundred -->
</div>
</div>
<button e2e="contactSubmit" class="button-primary ng-binding" tabindex="5" ng-bind="sendButton">Send Message</button>
<button tabindex="6" type="button" class="button ng-binding" ng-bind="back" ng-click="goPrevious();">Back</button>
</form>Name: forms.verifyEmailCodeForm —
<form name="forms.verifyEmailCodeForm" ng-submit="submitEmailCode()" novalidate="" class="ng-pristine ng-scope ng-invalid ng-invalid-required ng-valid-maxlength">
<div ng-messages="verifyNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: bruteForce -->
<!-- ngMessage: genericError -->
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.verifyEmailCodeForm.$invalid && forms.verifyEmailCodeForm.$submitted}">
<div class="input-area-field-wrapper">
<input name="emailVerificationCode" type="text" all-numeric="" required="" placeholder="Verification Code" ng-model="fields.emailVerificationCode" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}" maxlength="6"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required ng-valid-maxlength">
<a class="inline ng-binding" ng-click="resendVerification();">Resend</a>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyEmailCodeForm.emailVerificationCode.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>Name: forms.scodeAmountForm —
<form ng-controller="FindBillCtrl" name="forms.scodeAmountForm" ng-submit="linkBill()" novalidate="" class="ng-pristine ng-scope ng-valid-min ng-invalid ng-invalid-required ng-valid-maxlength">
<!-- FORM SUBMISSION RESPONSE FEEDBACK -->
<div ng-messages="searchErrors" class="interaction-feedback ng-inactive">
<!-- ngMessage: notFound -->
<!-- ngMessage: throttled -->
</div>
<!-- SECURECODE -->
<div class="input-area-wrapper" ng-class="{errored: forms.scodeAmountForm.scode.$invalid && (forms.scodeAmountForm.scode.$dirty || forms.scodeAmountForm.$submitted)}" id="securecode">
<div class="input-area-field-wrapper">
<i class="i-shield"></i>
<span class="autofillwidth">
<input sensitive="" ng-model="findData.sCode" type="text" required="" securecode-input="" name="scode" autocomplete="off" ng-model-options="{ debounce: 100 }" placeholder="SecureHealthCode on Bill"
title="Please enter the SecureHealthCode that is printed on your bill" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required" maxlength="11">
</span>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.scodeAmountForm.scode.$error" ng-show="forms.scodeAmountForm.$dirty || forms.scodeAmountForm.$submitted" class="ng-hide ng-active" style="">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-scope">
<div ng-bind-html="transworld ? 'transworld.clientRefNumRequired' : (subdomain ? 'whitelabel.' : '') + 'errors.scodeRequired' | translate" class="ng-binding">Please enter the SecureHealthCode located in the top right section of your bill.
</div>
</div>
<!-- ngMessage: allNumericSCode -->
</div>
</div>
</div>
<!-- AMOUNT -->
<div class="input-area-wrapper" autocomplete="off"
ng-class="{errored: (forms.scodeAmountForm.billAmount.$error.required || forms.scodeAmountForm.billAmount.$error.min) && (forms.scodeAmountForm.billAmount.$dirty || forms.scodeAmountForm.$submitted)}" id="amount">
<div class="input-area-field-wrapper">
<i class="i-dollar-sign"></i>
<span class="autofillwidth">
<input sensitive="" ng-model="findData.billAmount" currency="" suppress-dollar-sign="" type="text" name="billAmount" required="" min="0" maxlength="20" placeholder="Total Balance Due on Bill"
title="Please enter the Total Balance Due that is printed on your bill, even if you intend to actually pay a different amount"
class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-valid-min ng-invalid ng-invalid-required ng-valid-maxlength">
</span>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.scodeAmountForm.billAmount.$error" ng-show="forms.scodeAmountForm.$dirty || forms.scodeAmountForm.$submitted" class="ng-hide ng-active" style="">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please enter the total balance printed on your bill. We'll ask for your desired payment amount in the next step. </div>
<!-- ngMessage: min -->
</div>
</div>
</div>
<button class="button-primary button-callout submitFindBill ng-binding">Pay Bill</button>
</form>Name: forms.feedbackForm —
<form name="forms.feedbackForm" ng-submit="sendFeedback()" novalidate="" class="ng-pristine ng-valid ng-valid-maxlength">
<div class="comment-prompt ng-binding" ng-bind="commentPrompt"></div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type">
<textarea sensitive="" placeholder="Start typing feedback..." maxlength="5000" ng-model="feedback.comment" class="ng-pristine ng-untouched ng-valid fs-block ng-valid-maxlength"> </textarea>
</div>
</div>
<button e2e="feedbackSubmit" class="button-primary ng-binding" ng-bind="buttonText">Send Feedback</button>
</form>Name: forms.verifyAcctForm —
<form name="forms.verifyAcctForm" ng-submit="verifyAcct()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-incomplete ng-valid-future-date ng-valid-minlength">
<h2 class="modal-header h-style-2 ng-binding" ng-bind-html="header"></h2>
<h3 class="modal-subheader h-style-4 ng-binding" ng-bind-html="subheader"></h3>
<div class="interaction-feedback ng-binding ng-hide" ng-show="submitErrorMessage" ng-bind-html="submitErrorMessage"></div>
<div class="input-area-wrapper" ng-class="{errored: forms.verifyAcctForm.birthdate.$invalid && (forms.verifyAcctForm.$submitted || forms.verifyAcctForm.birthdate.$error.invalidDate || forms.verifyAcctForm.birthdate.$error.futureDate)}">
<div class="input-area-field-wrapper">
<input ng-model="fields.birthdate" type="text" pastdate="" required="" sensitive="" maxlength="10" autocomplete="off" name="birthdate" placeholder="Date of Birth (MM/DD/YYYY)"
class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-incomplete ng-valid-future-date">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyAcctForm.birthdate.$error" ng-show="forms.verifyAcctForm.$submitted || forms.verifyAcctForm.birthdate.$error.invalidDate || forms.verifyAcctForm.birthdate.$error.futureDate" class="ng-hide ng-active">
<!-- ngMessage: incomplete -->
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope">Please complete this field to continue.</div>
<!-- ngMessage: invalidDate -->
<!-- ngMessage: futureDate -->
</div>
</div>
</div>
<div class="input-area-wrapper" ng-class="{errored: (forms.verifyAcctForm.SSN.$invalid) && forms.verifyAcctForm.$submitted}">
<div class="input-area-field-wrapper">
<input ng-model="fields.SSN" type="text" name="SSN" required="" sensitive="" ng-minlength="4" maxlength="4" all-numeric="" placeholder="Last Four Digits of Social Security Number" autocomplete="off"
class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyAcctForm.SSN.$error" ng-show="forms.verifyAcctForm.$submitted" class="ng-hide ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope">Please complete this field to continue.</div>
<!-- ngMessage: minlength -->
</div>
</div>
</div>
<div ng-show="currAcctInfo.authType=='patient'" class="SSN-help-text explanation-text ng-binding ng-hide" ng-bind-html="'encounterLinking.ssnHelpInfo' | translate"><b>Note:</b> If you're adding accounts for an infant, use the guarantor's SSN</div>
<button class="button-primary button-callout submit-button ng-binding" ng-disabled="linkBlocked" ng-bind="submitButtonText"></button>
</form>Name: forms.verifyEmailCodeForm —
<form name="forms.verifyEmailCodeForm" ng-submit="submitEmailCode()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength">
<div ng-messages="verifyNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: bruteForce -->
<!-- ngMessage: genericError -->
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.verifyEmailCodeForm.$invalid && forms.verifyEmailCodeForm.$submitted}">
<div class="input-area-field-wrapper">
<input name="emailVerificationCode" type="text" inputmode="decimal" all-numeric="" required="" placeholder="Verification Code" ng-model="fields.emailVerificationCode" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}"
maxlength="6" class="ng-pristine ng-untouched ng-invalid ng-invalid-required ng-valid-maxlength">
<a class="inline" ng-click="sendCode(true);">Resend</a>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyEmailCodeForm.emailVerificationCode.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>Name: forms.verifySmsCodeForm —
<form name="forms.verifySmsCodeForm" ng-submit="submitSmsCode()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength">
<div ng-messages="verifyNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: bruteForce -->
<!-- ngMessage: genericError -->
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.verifySmsCodeForm.$invalid && forms.verifySmsCodeForm.$submitted}">
<div class="input-area-field-wrapper">
<input name="smsVerificationCode" type="text" inputmode="decimal" all-numeric="" required="" placeholder="Verification Code" ng-model="fields.smsVerificationCode" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}" maxlength="6"
autocomplete="off" class="ng-pristine ng-untouched ng-invalid ng-invalid-required ng-valid-maxlength">
<a class="inline" ng-click="sendCode(true);">Resend</a>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifySmsCodeForm.smsVerificationCode.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>Name: forms.verifyPdivForm —
<form name="forms.verifyPdivForm" ng-submit="submitPdiv()" novalidate="" class="ng-pristine ng-valid">
<div ng-messages="verifyNotifications" class="interaction-feedback ng-inactive">
<!-- ngMessage: bruteForce -->
<!-- ngMessage: genericError -->
</div>
<!-- ngIf: authOptions.pdivFields.guarantorDOB -->
<!-- ngIf: authOptions.pdivFields.guarantorLast4SSN -->
<!-- ngIf: authOptions.pdivFields.zip -->
</form>Name: forms.confirmPhoneForm —
<form ng-show="step == 'number'" name="forms.confirmPhoneForm" ng-submit="confirmPhoneNumber()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-hide ng-valid-minlength">
<h2 class="modal-header h-style-2 ng-binding">Complete Account Registration</h2>
<h3 class="modal-subheader h-style-4 ng-binding">Please verify your mobile phone number.</h3>
<div class="input-area-wrapper"
ng-class="{errored: (forms.confirmPhoneForm.phoneNumber.$error.required || forms.confirmPhoneForm.phoneNumber.$error.minlength || forms.confirmPhoneForm.phoneNumber.$error.smsEligible) && forms.confirmPhoneForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="phone" size="md" for="details-phone" active="forms.confirmPhoneForm.phoneNumber.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" version="1.1" focusable="false"
x="0px" y="0px" viewBox="0 0 51 51.3" enable-background="new 0 0 51 51.3" xml:space="preserve" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/phone-md.svg">
<path fill="#939598"
d="M1.9,13c0,0,1.1-5.3,4-8.8l3-2.2c0,0,3.4-0.8,7,4.6s2.5,7.7,2.5,7.7L15.2,18c0,0,0.3,3.4,1.9,5.6 s8.2,9.3,10,10.7c1.8,1.3,3.3,2.1,5.2,2.1l1.3-2.3c0,0,1.1-2,3.6-1.8c2.6,0.3,5.7,1.2,5.7,1.2S49.5,36,49,40l-1.2,3.8 c0,0-3.6,4.3-10.7,5.3c0,0-12.7-6.5-21.5-15.6S1.9,13,1.9,13z">
</path>
</svg></icon>
<input name="phoneNumber" type="text" phone-number="" required="" sms-eligible="" sensitive="" placeholder="Mobile Phone" on-phone-check-finished="asyncValidationComplete" ng-model="fields.phoneNumber" tabindex="0" maxlength="12"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-minlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.confirmPhoneForm.phoneNumber.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: minlength -->
<!-- ngMessage: smsEligible -->
</div>
</div>
<span>
<div ng-bind-html="(subdomain ? 'whitelabel.' : '') + 'confirmPhone.explanation' | translate" class="ng-binding">You will receive a text message with a unique code to verify your mobile phone number.</div>
</span>
</div>
</form>Name: forms.verifyCodeForm —
<form ng-show="step == 'code'" name="forms.verifyCodeForm" ng-submit="verifyCode()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-hide">
<h2 class="modal-header h-style-2 ng-binding">Complete Account Registration</h2>
<h3 class="modal-subheader h-style-4 ng-binding">Please enter the code we sent to your mobile device via SMS.</h3>
<div class="input-area-wrapper" ng-class="{errored: (forms.confirmPhoneForm.phoneNumber.$error.required || forms.confirmPhoneForm.phoneNumber.$error.minlength) && forms.confirmPhoneForm.$submitted}">
<div class="input-area-field-wrapper">
<input name="code" type="text" all-numeric="" required="" placeholder="Verification Code" ng-model="fields.code" tabindex="0" maxlength="6" autocomplete="off" class="ng-pristine ng-untouched ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.verifyCodeForm.code.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>Name: forms.confirmEmailForm —
<form name="forms.confirmEmailForm" ng-submit="confirmEmail()" novalidate="" class="ng-pristine ng-valid-email ng-invalid ng-invalid-required">
<h2 class="modal-header h-style-2 ng-binding">Verify Email Address</h2>
<div class="input-area-wrapper" ng-class="{errored: forms.confirmEmailForm.email.$invalid && forms.confirmEmailForm.email.$touched}">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="details-email" active="forms.confirmEmailForm.email.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope"
data-containertransform="scale(1 1 ) translate(0 5 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input required="" name="email" type="email" id="details-email" sensitive="" placeholder="Email Address" on-email-check-finished="emailValidated" is-update="true" ng-model="fields.email" valid-email="" email-available=""
ng-model-options="{updateOn: 'blur submit'}" class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.confirmEmailForm.email.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: email -->
<!-- ngMessage: emailAvailable -->
</div>
</div>
<span class="explanation ng-binding">Is the email address listed correct? If not, please correct it above prior to clicking the "Send Email" button to update your account.</span>
</div>
</form>Name: forms.echeckForm —
<form novalidate="" name="forms.echeckForm" ng-submit="method.submitAndMove()" class="ng-pristine ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength ng-valid-mismatch">
<div class="split-input-areas-container">
<!-- FIRST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.firstName.$invalid && forms.echeckForm.$submitted}">
<div class="input-area-field-wrapper">
<input sensitive="" valid-name="" type="text" required="" name="firstName" ng-model="method.eCheck.firstName" placeholder="First Name" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.echeckForm.firstName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- LAST NAME -->
<div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.lastName.$invalid && forms.echeckForm.$submitted}">
<div class="input-area-field-wrapper">
<input sensitive="" valid-name="" type="text" required="" name="lastName" ng-model="method.eCheck.lastName" placeholder="Last Name" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.echeckForm.lastName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</div>
<!-- ROUTING NUMBER -->
<div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.routing.$invalid && (forms.echeckForm.routing.$error.validRouting || forms.echeckForm.$submitted)}">
<div class="input-area-field-wrapper">
<input sensitive="" type="tel" name="routing" required="" ng-minlength="9" maxlength="9" all-numeric="" routing-number="" on-bank-found="method.applyBank(bankName)" ng-model="method.eCheck.routing" placeholder="Routing Number"
on-routing-number-check-finished="routingNumberValidated" class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<!-- ngIf: forms.echeckForm.routing.$invalid && (forms.echeckForm.routing.$error.validRouting || forms.echeckForm.$submitted) -->
</div>
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.accountNumber.$invalid && forms.echeckForm.$submitted}">
<div class="input-area-field-wrapper">
<input sensitive="" type="tel" required="" maxlength="25" ng-minlength="4" name="accountNumber" all-numeric="" ng-cut="$event.preventDefault()" ng-copy="$event.preventDefault()" ng-model="method.eCheck.accountNumber"
placeholder="Account Number" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.echeckForm.accountNumber.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: minlength -->
</div>
</div>
</div>
<div class="input-area-wrapper" ng-class="{errored: forms.echeckForm.accountNumberConfirm.$invalid && forms.echeckForm.$submitted}">
<div class="input-area-field-wrapper">
<input sensitive="" type="tel" maxlength="25" ng-minlength="4" all-numeric="" ng-cut="$event.preventDefault()" ng-copy="$event.preventDefault()" ng-paste="$event.preventDefault()" name="accountNumberConfirm" required=""
match="method.eCheck.accountNumber" ng-model="method.eCheck.accountNumberConfirm" placeholder="Confirm Account Number"
class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength ng-valid-mismatch">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.echeckForm.accountNumberConfirm.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: mismatch -->
</div>
</div>
</div>
<button class="button-primary payment-next-step-button ng-binding"> Continue </button>
</form>Name: forms.billing —
<form novalidate="" name="forms.billing" ng-submit="billing.submitAndMove()" class="ng-pristine ng-scope ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
<!-- ADDRESS 1 -->
<div class="input-area-wrapper" ng-class="{errored: forms.billing.addr1.$invalid && (forms.billing.addr1.$dirty || forms.billing.$submitted)}">
<div class="input-area-field-wrapper">
<input sensitive="" type="text" required="" name="addr1" ng-model="billing.fields.address" placeholder="Address" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.billing.addr1.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- ADDRESS 2 -->
<div class="input-area-wrapper">
<div class="input-area-field-wrapper">
<input sensitive="" type="text" name="addr2" ng-model="billing.fields.address2" placeholder="Address Line 2 (optional)" class="ng-pristine ng-untouched ng-valid fs-block">
</div>
</div>
<!-- CITY -->
<div class="input-area-wrapper" ng-class="{errored: forms.billing.city.$invalid && (forms.billing.city.$dirty || forms.billing.$submitted)}">
<div class="input-area-field-wrapper">
<input sensitive="" type="text" required="" name="city" ng-model="billing.fields.city" placeholder="City" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.billing.city.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- STATE -->
<div class="input-area-wrapper" ng-class="{errored: forms.billing.state.$invalid && (forms.billing.state.$dirty || forms.billing.$submitted)}">
<div class="input-area-field-wrapper">
<select required="" ng-options="state.abbreviation as state.name for state in states" ng-model="billing.fields.state" name="state" ng-class="{'empty-value': !billing.fields.state}" class="ng-scope ng-invalid ng-invalid-required empty-value">
<option value="" disabled="" class="ng-binding">Select State</option>
<option value="0" label="Alabama">Alabama</option>
<option value="1" label="Alaska">Alaska</option>
<option value="2" label="Arizona">Arizona</option>
<option value="3" label="Arkansas">Arkansas</option>
<option value="4" label="California">California</option>
<option value="5" label="Colorado">Colorado</option>
<option value="6" label="Connecticut">Connecticut</option>
<option value="7" label="Delaware">Delaware</option>
<option value="8" label="District of Columbia">District of Columbia</option>
<option value="9" label="Florida">Florida</option>
<option value="10" label="Georgia">Georgia</option>
<option value="11" label="Hawaii">Hawaii</option>
<option value="12" label="Idaho">Idaho</option>
<option value="13" label="Illinois">Illinois</option>
<option value="14" label="Indiana">Indiana</option>
<option value="15" label="Iowa">Iowa</option>
<option value="16" label="Kansas">Kansas</option>
<option value="17" label="Kentucky">Kentucky</option>
<option value="18" label="Louisiana">Louisiana</option>
<option value="19" label="Maine">Maine</option>
<option value="20" label="Maryland">Maryland</option>
<option value="21" label="Massachusetts">Massachusetts</option>
<option value="22" label="Michigan">Michigan</option>
<option value="23" label="Minnesota">Minnesota</option>
<option value="24" label="Mississippi">Mississippi</option>
<option value="25" label="Missouri">Missouri</option>
<option value="26" label="Montana">Montana</option>
<option value="27" label="Nebraska">Nebraska</option>
<option value="28" label="Nevada">Nevada</option>
<option value="29" label="New Hampshire">New Hampshire</option>
<option value="30" label="New Jersey">New Jersey</option>
<option value="31" label="New Mexico">New Mexico</option>
<option value="32" label="New York">New York</option>
<option value="33" label="North Carolina">North Carolina</option>
<option value="34" label="North Dakota">North Dakota</option>
<option value="35" label="Ohio">Ohio</option>
<option value="36" label="Oklahoma">Oklahoma</option>
<option value="37" label="Oregon">Oregon</option>
<option value="38" label="Pennsylvania">Pennsylvania</option>
<option value="39" label="Rhode Island">Rhode Island</option>
<option value="40" label="South Carolina">South Carolina</option>
<option value="41" label="South Dakota">South Dakota</option>
<option value="42" label="Tennessee">Tennessee</option>
<option value="43" label="Texas">Texas</option>
<option value="44" label="Utah">Utah</option>
<option value="45" label="Vermont">Vermont</option>
<option value="46" label="Virginia">Virginia</option>
<option value="47" label="Washington">Washington</option>
<option value="48" label="West Virginia">West Virginia</option>
<option value="49" label="Wisconsin">Wisconsin</option>
<option value="50" label="Wyoming">Wyoming</option>
<option value="51" label="American Samoa">American Samoa</option>
<option value="52" label="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="53" label="Guam">Guam</option>
<option value="54" label="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="55" label="Marshall Islands">Marshall Islands</option>
<option value="56" label="Palau">Palau</option>
<option value="57" label="Puerto Rico">Puerto Rico</option>
<option value="58" label="Virgin Islands">Virgin Islands</option>
<option value="59" label="Armed Forces">Armed Forces</option>
<option value="60" label="Armed Forces Americas">Armed Forces Americas</option>
<option value="61" label="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
</div>
<div class="input-area-feedback">
<div ng-messages="forms.billing.state.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- ZIP -->
<div class="input-area-wrapper" ng-class="{errored: forms.billing.zip.$invalid && forms.billing.$submitted}">
<div class="input-area-field-wrapper">
<input required="" sensitive="" type="tel" ng-model="billing.fields.zip" all-numeric="" name="zip" maxlength="5" ng-minlength="5" placeholder="Zip Code"
class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required ng-valid-minlength ng-valid-maxlength">
</div>
<!-- ngIf: forms.billing.$submitted -->
</div>
<button class="button-primary payment-next-step-button ng-binding"> Continue </button>
</form>Name: forms.confirmPasswordForm —
<form name="forms.confirmPasswordForm" ng-submit="confirm()" novalidate="" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength">
<div class="input-area-wrapper" ng-class="{errored: forms.confirmPasswordForm.password.$invalid && forms.confirmPasswordForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="current-pass" active="forms.confirmPasswordForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="password" type="password" maxlength="255" id="current-pass" sensitive="" placeholder="Password" ng-model="fields.password"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-feedback">
<div ng-messages="forms.confirmPasswordForm.password.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>Name: forms.myChartForm —
<form ng-submit="checkForPatientWalletAccount()" name="forms.myChartForm" novalidate="" class="ng-pristine ng-scope ng-valid-email ng-invalid ng-invalid-required">
<h2 class="modal-header h-style-2 ng-binding" ng-bind-html="welcomeMessage"></h2>
<div class="modal-text ng-binding" ng-bind-html="'myChartSSO.patientWalletDescription' | translate">The PatientWallet is where you'll be able to access all of your bills and make payments.<br><br>Let's check to see if you already have an account.
</div>
<div class="input-area-wrapper solo-input" ng-class="{errored: (emailInput.$invalid && emailInput.$touched) || (forms.myChartForm.$invalid && forms.myChartForm.$submitted)}">
<div class="input-area-field-wrapper">
<input name="checkEmail" valid-email="" type="email" sensitive="" required="" placeholder="Enter your email address" ng-model="fields.email" ng-model-options="{updateOn: 'default'}" ng-blur="touchedCheckEmail()"
class="ng-pristine ng-untouched ng-isolate-scope fs-block ng-valid-email ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="emailInput.$error" class="ng-inactive">
<!-- ngMessage: alreadyLinked -->
</div>
<div ng-messages="forms.myChartForm.$error" class="ng-inactive">
<!-- ngMessage: email -->
</div>
</div>
</div>
<button id="check-for-patient-wallet-button" class="button button-primary ng-binding" tabindex="8" ng-bind-html="(searching ? 'myChartSSO.checkForPatientWalletAccountPending' : 'myChartSSO.checkForPatientWalletAccount') | translate">Search</button>
</form><form ng-submit="verifyEmail()" class="ng-pristine ng-scope ng-invalid ng-invalid-required">
<!-- ngIf: foundMatch -->
<!-- ngIf: !foundMatch -->
<h2 class="modal-header h-style-2 ng-binding ng-scope" ng-if="!foundMatch"> Set Up Your PatientWallet </h2><!-- end ngIf: !foundMatch -->
<!-- envelope icon -->
<svg xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:cc="http://creativecommons.org/ns#" xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#" xmlns:svg="http://www.w3.org/2000/svg" xmlns="http://www.w3.org/2000/svg"
xmlns:sodipodi="http://sodipodi.sourceforge.net/DTD/sodipodi-0.dtd" xmlns:inkscape="http://www.inkscape.org/namespaces/inkscape" version="1.1" x="0px" y="0px" viewBox="0 0 100 125" style="max-width: 100px;margin-bottom: -30px;fill:#616161;">
<g transform="translate(0,-952.36218)">
<path style="text-indent:0;text-transform:none;direction:ltr;block-progression:tb;baseline-shift:baseline;color:#000000;enable-background:accumulate;"
d="m 6.0000002,973.36217 a 2.0002,2.0002 0 0 0 -2,2 l 0,54.00003 a 2.0002,2.0002 0 0 0 2,2 l 87.9999998,0 a 2.0002,2.0002 0 0 0 2,-2 l 0,-54.00003 a 2.0002,2.0002 0 0 0 -2,-2 l -87.9999998,0 z m 5.4687498,4 77.0625,0 L 50,1009.7684 11.46875,977.36217 z m -3.4687498,2.28125 25.9687498,21.84378 -25.9687498,23.375 0,-45.21878 z m 83.9999998,0 0,45.21878 -25.96875,-23.375 L 92,979.64342 z m -54.9375,24.43748 11.65625,9.8125 a 2.0002,2.0002 0 0 0 2.5625,0 l 11.65625,-9.8125 25.875,23.2813 -77.625,0 25.875,-23.2813 z"
fill-opacity="1" stroke="none" marker="none" visibility="visible" display="inline" overflow="visible"></path>
</g>
</svg><br>
<div class="notification-inline failure notification ng-isolate-scope ng-hide" ng-class="{closable: closable, 'has-icon': hasIcon}" ng-show="codeNotSent">
<div class="primary-icon-container u-center-vertical">
<icon name="" class="ng-isolate-scope"><img data-src="" name="" class="iconic" iconic="" ng-class="{ 'icon-active': active}"></icon>
</div>
<div class="notification-content-container u-center-vertical">
<div class="notification-content" ng-transclude="">
<icon name="circle-x" size="sm" class="ng-scope ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-x" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-x-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm-5 8.875l5 5 5-5 2.125 2.125-5 5 5 5-2.125 2.125-5-5-5 5-2.125-2.125 5-5-5-5 2.125-2.125z"></path>
</svg></icon><span class="ng-binding ng-scope"> There was a problem sending that code. Please try again. </span>
</div>
</div>
<div class="notification-close u-center-vertical" ng-click="closeNotification()">
<icon name="x" size="sm" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="x" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic"
data-src="/releases/0ff84c1/assets/icons/x-md.svg">
<path
d="M4.5.25l-4.25 4.25 2.125 2.125 9.375 9.375-9.375 9.375-2.125 2.125 4.25 4.25 2.125-2.125 9.375-9.375 9.375 9.375 2.125 2.125 4.25-4.25-2.125-2.125-9.375-9.375 9.375-9.375 2.125-2.125-4.25-4.25-2.125 2.125-9.375 9.375-9.375-9.375-2.125-2.125z">
</path>
</svg></icon>
</div>
</div>
<div class="notification-inline success notification ng-isolate-scope ng-hide" ng-class="{closable: closable, 'has-icon': hasIcon}" ng-show="codeSent">
<div class="primary-icon-container u-center-vertical">
<icon name="" class="ng-isolate-scope"><img data-src="" name="" class="iconic" iconic="" ng-class="{ 'icon-active': active}"></icon>
</div>
<div class="notification-content-container u-center-vertical">
<div class="notification-content" ng-transclude="">
<icon name="circle-check" size="sm" class="ng-scope ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon><span class="ng-binding ng-scope"> Code has been sent. </span>
</div>
</div>
<div class="notification-close u-center-vertical" ng-click="closeNotification()">
<icon name="x" size="sm" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="x" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic"
data-src="/releases/0ff84c1/assets/icons/x-md.svg">
<path
d="M4.5.25l-4.25 4.25 2.125 2.125 9.375 9.375-9.375 9.375-2.125 2.125 4.25 4.25 2.125-2.125 9.375-9.375 9.375 9.375 2.125 2.125 4.25-4.25-2.125-2.125-9.375-9.375 9.375-9.375 2.125-2.125-4.25-4.25-2.125 2.125-9.375 9.375-9.375-9.375-2.125-2.125z">
</path>
</svg></icon>
</div>
</div>
<div class="modal-text ng-binding fs-block" ng-bind-html="verifyEmailPrompt" sensitive=""></div>
<!-- ngIf: badVerificationAttempt -->
<div class="input-area-field-wrapper solo-input">
<input name="emailVerificationCode" type="text" sensitive="" required="" placeholder="Verification Code" ng-model="fields.verificationCode" class="ng-pristine ng-untouched fs-block ng-invalid ng-invalid-required">
<a class="inline ng-binding" ng-click="resendVerification()">Resend</a>
</div>
<!-- ngIf: !foundMatch -->
<div ng-if="!foundMatch" id="terms-of-use-input" class="input-area-wrapper ng-scope">
<div class="input-area-field-wrapper no-initial-border inline-input-type">
<input required="" id="acceptTerms" name="acceptTerms" type="checkbox" ng-model="fields.acceptTerms" tabindex="8" class="ng-pristine ng-untouched ng-invalid ng-invalid-required">
<label for="acceptTerms" class="create-account-terms" compile="'labels.acceptanceOfTerms' | translate"><span class="ng-scope">I agree to the
</span><a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank" class="ng-scope">Terms of Use</a></label>
</div>
</div><!-- end ngIf: !foundMatch -->
<button id="verify-email-button" class="button button-primary ng-binding" ng-disabled="verifying"> Verify </button>
<div>
<a ng-click="useDifferentEmail()" class="ng-binding">Use a different email address</a>
</div>
</form>Name: finishRegistrationForm —
<form name="finishRegistrationForm" novalidate=""
class="ng-pristine ng-scope ng-invalid ng-invalid-required ng-valid-email ng-valid-maxlength ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-valid-minlength ng-valid-mismatch ng-valid-sms-eligible">
<div class="split-input-areas-container">
<!-- FIRST NAME -->
<div class="input-area-wrapper" ng-class="{errored: finishRegistrationForm.firstName.$invalid && finishRegistrationForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="finishRegistration-first" active="finishRegistrationForm.firstName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="firstName" type="text" id="finishRegistration-first" sensitive="" valid-name="" placeholder="First Name" ng-model="finishRegistrationFields.firstName" tabindex="1"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="finishRegistrationForm.firstName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
<!-- LAST NAME -->
<div class="input-area-wrapper" ng-class="{errored: finishRegistrationForm.lastName.$invalid && finishRegistrationForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="person-genderless" size="sm" for="finishRegistration-last" active="finishRegistrationForm.lastName.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="person"
data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/person-genderless-md.svg">
<path
d="M16 0c-4.4 0-8 3.5-8 9s2.5 11 8 11c5.4 0 8-5.5 8-11s-3.6-9-8-9zm-8 20c-4.4 0-8 3.6-8 8v3.5c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-3.5c0-4.4-3.6-8-8-8h-.406c-.2 0-.581.212-.781.313-1.8 1.7-4.212 2.688-6.813 2.688-2.6 0-5.012-.988-6.813-2.688-.2-.1-.481-.313-.781-.313h-.406z">
</path>
</svg></icon>
<input required="" name="lastName" type="text" id="finishRegistration-last" sensitive="" valid-name="" placeholder="Last Name" ng-model="finishRegistrationFields.lastName" tabindex="2"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-required">
</div>
<div class="input-area-feedback">
<div ng-messages="finishRegistrationForm.lastName.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
</div>
</div>
</div>
</div>
<!-- EMAIL -->
<div class="input-area-wrapper">
<div class="input-area-field-wrapper">
<icon name="envelope-closed" size="sm" for="finishRegistration-email" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 5 )"
data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/envelope-closed-md.svg">
<path
d="M.5 0c-.3 0-.5.2-.5.5v2c0 .3.206.587.406.688l15.094 7.625c.3.1.706.1.906 0l15.094-7.625c.3-.1.5-.388.5-.688v-2c0-.3-.2-.5-.5-.5h-31zm-.25 6.156c-.141 0-.25.119-.25.344v15c0 .3.2.5.5.5h31c.3 0 .5-.2.5-.5v-15c0-.3-.206-.412-.406-.313l-15.094 7.625c-.3.1-.706.1-.906 0l-15.188-7.625c-.05-.025-.109-.031-.156-.031z"
transform="translate(0 5)"></path>
</svg></icon>
<input required="" name="email" type="email" sensitive="" disabled="" autocapitalize="off" autocorrect="off" autosuggest="off" id="finishRegistration-email" placeholder="Email Address" ng-model="finishRegistrationFields.email" tabindex="3"
maxlength="255" ng-model-options="{ updateOn: 'blur submit' }" class="ng-pristine ng-untouched input-with-icon fs-block ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength">
</div>
</div>
<!-- PHONE -->
<div class="input-area-wrapper" ng-class="{errored: finishRegistrationForm.phone.$invalid && finishRegistrationForm.phone.$touched}">
<div class="input-area-field-wrapper">
<icon name="phone" size="md" for="finishRegistration--phone" active="finishRegistrationForm.phone.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" version="1.1"
focusable="false" x="0px" y="0px" viewBox="0 0 51 51.3" enable-background="new 0 0 51 51.3" xml:space="preserve" class="injected-svg iconic icon-for-input" data-src="/releases/0ff84c1/assets/icons/phone-md.svg">
<path fill="#939598"
d="M1.9,13c0,0,1.1-5.3,4-8.8l3-2.2c0,0,3.4-0.8,7,4.6s2.5,7.7,2.5,7.7L15.2,18c0,0,0.3,3.4,1.9,5.6 s8.2,9.3,10,10.7c1.8,1.3,3.3,2.1,5.2,2.1l1.3-2.3c0,0,1.1-2,3.6-1.8c2.6,0.3,5.7,1.2,5.7,1.2S49.5,36,49,40l-1.2,3.8 c0,0-3.6,4.3-10.7,5.3c0,0-12.7-6.5-21.5-15.6S1.9,13,1.9,13z">
</path>
</svg></icon>
<input name="phone" type="text" id="finishRegistration-phone" phone-number="" sms-eligible="" sensitive="" placeholder="Mobile Phone" on-phone-check-finished="asyncValidationComplete" ng-model="finishRegistrationFields.phoneNumber" tabindex="4"
ng-model-options="{updateOn: 'default blur submit'}" maxlength="12" class="ng-pristine ng-untouched ng-valid input-with-icon ng-isolate-scope fs-block ng-valid-maxlength ng-valid-minlength ng-valid-sms-eligible">
</div>
<div class="input-area-feedback">
<div ng-messages="finishRegistrationForm.phone.$error" class="ng-inactive">
<!-- ngMessage: minlength -->
<!-- ngMessage: smsEligible -->
</div>
</div>
</div>
<!-- PASSWORD -->
<div class="input-area-wrapper login-password-input-area" ng-class="{
errored: finishRegistrationForm.password.$invalid && finishRegistrationForm.$submitted,
'login-password-incorect-blurred': finishRegistrationForm.password.$dirty && finishRegistrationForm.password.$invalid
}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="finishRegistration-pass" active="finishRegistrationForm.password.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="password" type="password" valid-password="" id="finishRegistration-pass" maxlength="255" sensitive="" placeholder="Password" ng-model="finishRegistrationFields.password" tabindex="5"
class="ng-pristine ng-untouched input-with-icon fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-maxlength">
</div>
<div class="input-area-rules">
<ul>
<li ng-class="{'rule-met': !finishRegistrationForm.password.$error.minCharactersRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 8 characters
</li>
<li ng-class="{'rule-met': !finishRegistrationForm.password.$error.upperCaseRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 uppercase letter
</li>
<li ng-class="{'rule-met': !finishRegistrationForm.password.$error.digitRule}" class="ng-binding">
<icon name="shape-circle" size="sm" class="rule-met-icon ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" data-icon="circle-check" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32"
class="injected-svg iconic" data-src="/releases/0ff84c1/assets/icons/circle-check-md.svg">
<path d="M16 0c-8.837 0-16 7.163-16 16s7.163 16 16 16 16-7.163 16-16-7.163-16-16-16zm6.906 8.875l2.219 2.031-12.063 13.281-6.188-6.188 2.125-2.125 3.938 3.938 9.969-10.938z"></path>
</svg></icon> 1 number
</li>
</ul>
</div>
</div>
<!-- CONFIRM PASSWORD -->
<div class="input-area-wrapper" ng-class="{errored: finishRegistrationForm.password.$valid && finishRegistrationForm.confirmPassword.$invalid && finishRegistrationForm.$submitted}">
<div class="input-area-field-wrapper">
<icon name="lock-locked" size="sm" for="finishRegistration-con-pass" active="finishRegistrationForm.confirmPassword.$dirty" class="ng-isolate-scope"><svg xmlns="http://www.w3.org/2000/svg" focusable="false" data-icon="lock"
data-containertransform="scale(1 1 ) translate(4 2 )" data-width="null" data-height="null" version="1.1" width="32" height="32" viewBox="0 0 32 32" class="injected-svg iconic icon-for-input"
data-src="/releases/0ff84c1/assets/icons/lock-locked-md.svg">
<path d="M12 0c-4.406 0-8 3.594-8 8v4h-4v11h24v-11h-4v-4c0-4.406-3.594-8-8-8zm0 3c2.794 0 5 2.206 5 5v4h-10v-4c0-2.794 2.206-5 5-5zm-12 21v4h24v-4h-24z" transform="translate(4 2)"></path>
</svg></icon>
<input required="" name="confirmPassword" type="password" id="finishRegistration-con-pass" match="finishRegistrationFields.password" valid-password="" sensitive="" placeholder="Confirm Password"
ng-model="finishRegistrationFields.confirmPassword" tabindex="6"
class="ng-pristine ng-untouched input-with-icon ng-isolate-scope fs-block ng-invalid ng-invalid-min-characters-rule ng-invalid-upper-case-rule ng-invalid-digit-rule ng-invalid-required ng-valid-mismatch">
</div>
<div class="input-area-feedback">
<div ng-messages="finishRegistrationForm.confirmPassword.$error" class="ng-active">
<!-- ngMessage: required -->
<div ng-message="required" class="ng-binding ng-scope"> Please complete this field to continue. </div>
<!-- ngMessage: mismatch -->
</div>
</div>
</div>
<div class="register-checkboxes">
<!-- SMS OPT-IN -->
<div class="input-area-wrapper" ng-class="{errored: finishRegistrationForm.receivesSms.$invalid && finishRegistrationForm.$submitted}">
<div class="input-area-field-wrapper no-initial-border inline-input-type">
<input id="finishRegistration-receivesSms" name="receivesSms" type="checkbox" ng-model="finishRegistrationFields.receivesSms" tabindex="7" class="ng-pristine ng-untouched ng-valid">
<label for="finishRegistration-receivesSms" class="create-account-terms" compile="'labels.receivesSms' | translate"><span class="ng-scope">Text me new bills & reminders</span></label>
</div>
</div>
</div>
<button class="button button-primary ng-binding" ng-disabled="submittingFinishRegistration" ng-click="finishRegistration();" tabindex="8"> Save </button>
</form>Text Content
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PATIENTCO
Patientco
Enter the unique details from your bill.
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entered. Please check to make sure your details are correct.
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ability to search for bills has been disabled for a few minutes.
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Welcome to the PatientWallet® from Patientco! We’ve partnered with your
healthcare provider to give you the simplest, most secure payment experience
possible.
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Patientco
© 2022
About
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Terms
You are now being redirected to your PatientWallet®
An error occurred while attempting to redirect you to your PatientWallet®.
Please try again, and if you continue to have problems please contact your
provider.
There was a problem sending that code. Please try again.
That code was invalid or expired. Please try again.
WELCOME TO YOUR PATIENTWALLET®
Create Account Log In
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* 8 characters
* 1 uppercase letter
* 1 number
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Text me new bills & reminders
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For legal reasons, we require all users to accept our Terms of Use.
Create Account
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WE'VE GOT YOU COVERED.
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I didn't receive a code Next
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.
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CREATE YOUR NEW PASSWORD.
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* 1 uppercase letter
* 1 number
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Reset Password
INPUT MESSAGE
New Message
Select a Provider
Select an Account
Select a Reason
Message
Attach a file
Cancel SEND
{{name}} does not support messaging through Patientco. If you would like to
contact your provider, please call {{billingPhoneNumber}}. We apologize for any
inconvenience.
Your PatientWallet® is currently empty. Please add a new bill to get started.
I NEED HELP WITH:
Understanding my bill I need an itemized bill I lost my Patientco bill Logging
in Reset my password
I HAVE A QUESTION ABOUT:
A charge on my bill Creating a payment plan A duplicate charge or bill Missing
payments Updating Information Insurance Requesting an itemized bill Financial
assistance Estimate Other Back
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Please enter your email address:
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Please enter the SecureHealthCode located in the top right section of your bill.
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payment amount in the next step.
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ALMOST THERE...
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* 1 uppercase letter
* 1 number
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I agree to the Terms of Use
For legal reasons, we require all users to accept our Terms of Use.
Submit Back
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PLEASE REACH OUT TO US DIRECTLY AT
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ALMOST THERE...
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Forgot Your Password?
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THANKS FOR REACHING OUT!
WE'RE EXCITED TO HEAR FROM YOU.
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Send Message Back
UPDATES TO TERMS OF USE
& PRIVACY POLICY
We have updated our Terms of Use and Privacy Policy to make it easier for you to
understand what information we collect and why.
As a friendly reminder, Patientco will never share your information with third
party marketers, and you can always update your Communication Preferences within
your Settings. We encourage you to review our new Terms of Use and Privacy
Policy.
To accept the new Terms of Use and Privacy Policy, click "Accept" below.
Accept
VERIFY EMAIL
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NOTIFICATIONS
WHICH BILL WOULD YOU LIKE TO PAY?
Pay New Bill
ENTER DETAILS FROM YOUR NEW BILL.
Please enter the SecureHealthCode located in the top right section of your bill.
Please enter the total balance printed on your bill. We'll ask for your desired
payment amount in the next step.
Pay Bill
Send Feedback
WHO WOULD YOU LIKE TO VERIFY?
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Note: If you're adding accounts for an infant, use the guarantor's SSN
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CHECK YOUR EMAIL!
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PLEASE VERIFY YOUR MOBILE PHONE NUMBER.
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You will receive a text message with a unique code to verify your mobile phone
number.
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PLEASE ENTER THE CODE WE SENT TO YOUR MOBILE DEVICE VIA SMS.
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By verifying your phone number, you agree to allow Patientco to send you
periodic text messages on behalf of your provider for any account-related
activity. Patientco may use an automated system to send you electronic
communications including text, phone, or email. Patientco does not have a
separate charge for this service; however, subject to the terms and conditions
of your mobile carrier, message and data rates may apply. By providing your
consent to participate in this program, you approve any such charges from your
mobile carrier. You may opt out of this program at any time by emailing
Patientco at support@patientco.com.
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VERIFY EMAIL ADDRESS
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clicking the "Send Email" button to update your account.
Method Address Confirmation
eCheck Credit/Debit Card
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* Method
* eCheck Billing Address
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The PatientWallet is where you'll be able to access all of your bills and make
payments.
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SET UP YOUR PATIENTWALLET
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finish setting up your account by adding your phone number and a password.
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BROWSER INFO
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* IP:
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APPLICATION INFO
* Root URL: https://www.gopatientco.com/
* Base URL: /releases/0ff84c1/
* API URL: /api
* Backendless: false
* Environment: production
* Languages: ["en","es"]
* Pendo Enabled: false
* Version: 0ff84c1
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