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ubermenu-responsive-toggle-main ubermenu-skin-vanilla ubermenu-loc- ubermenu-responsive-toggle-content-align-left ubermenu-responsive-toggle-align-full " tabindex="0" data-ubermenu-target="ubermenu-main-1"><i class="fas fa-bars" ></i>Menu</a><nav id="ubermenu-main-1" class="ubermenu ubermenu-nojs ubermenu-main ubermenu-menu-1 ubermenu-responsive ubermenu-responsive-default ubermenu-responsive-collapse ubermenu-horizontal ubermenu-transition-shift ubermenu-trigger-hover_intent ubermenu-skin-vanilla ubermenu-bar-align-right ubermenu-items-align-auto ubermenu-disable-submenu-scroll ubermenu-sub-indicators ubermenu-retractors-responsive ubermenu-submenu-indicator-closes"><ul id="ubermenu-nav-main-1" class="ubermenu-nav" data-title="Primary Menu"><li id="menu-item-628" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-home ubermenu-item-628 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="https://senahealth.com/" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Home</span></a></li><li id="menu-item-636" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-item-636 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-flyout" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Who We Are</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-636 ubermenu-submenu-type-flyout ubermenu-submenu-drop ubermenu-submenu-align-left_edge_item" ><li id="menu-item-635" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-635 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-1" ><a class="ubermenu-target ubermenu-target-with-icon ubermenu-item-layout-default ubermenu-item-layout-icon_left" href="https://senahealth.com/our-team/"><i class="ubermenu-icon fas fa-user" ></i><span class="ubermenu-target-title ubermenu-target-text">Our Team</span></a><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><p id="subMtext">Meet our experienced team of advocates.</p></div></li><li id="menu-item-634" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-634 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-1" ><a class="ubermenu-target ubermenu-target-with-icon ubermenu-item-layout-default ubermenu-item-layout-icon_left" href="https://senahealth.com/our-story/"><i class="ubermenu-icon fas fa-heart" ></i><span class="ubermenu-target-title ubermenu-target-text">Our Story</span></a><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><p id="subMtext">It all started with a passion from humble beginnings.</p></div></li></ul></li><li id="menu-item-2165" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-item-2165 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-flyout" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Our Services</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-2165 ubermenu-submenu-type-flyout ubermenu-submenu-drop ubermenu-submenu-align-left_edge_item" ><li id="menu-item-1861" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1861 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-1" ><a class="ubermenu-target ubermenu-target-with-icon ubermenu-item-layout-default ubermenu-item-layout-icon_left" href="https://senahealth.com/heal-at-home/"><i class="ubermenu-icon fas fa-home" ></i><span class="ubermenu-target-title ubermenu-target-text">SENA at Home</span></a><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><p id="subMtext">High quality care in the home.</p></div></li><li id="menu-item-1862" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1862 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-1" ><a class="ubermenu-target ubermenu-target-with-icon ubermenu-item-layout-default ubermenu-item-layout-icon_left" href="https://senahealth.com/employee-health-wellness/"><i class="ubermenu-icon fas fa-briefcase" ></i><span class="ubermenu-target-title ubermenu-target-text">SENA at Work</span></a><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><p id="subMtext">Employee Care Navigation with a 4:1 ROI.</p></div></li><li id="menu-item-2164" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-2164 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-1" ><a class="ubermenu-target ubermenu-target-with-icon ubermenu-item-layout-default ubermenu-item-layout-icon_left" href="https://senahealth.com/clinical-command-center/"><i class="ubermenu-icon fas fa-user" ></i><span class="ubermenu-target-title ubermenu-target-text">Clinical Command Center</span></a><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><p id="subMtext">High-tech, High-touch clinical coordination.</p></div></li></ul></li><li id="menu-item-638" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-advanced-sub ubermenu-item-638 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-mega" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Resources</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><div class="ubermenu-submenu ubermenu-submenu-id-638 ubermenu-submenu-type-auto ubermenu-submenu-type-mega ubermenu-submenu-drop ubermenu-submenu-align-full_width ubermenu-autoclear" ><ul class="ubermenu-row ubermenu-row-id-736 ubermenu-autoclear "><li class=" ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-has-children ubermenu-item-738 ubermenu-item-level-2 ubermenu-column ubermenu-column-2-3 ubermenu-has-submenu-stack ubermenu-item-type-column ubermenu-column-id-738"><ul class="ubermenu-submenu ubermenu-submenu-id-738 ubermenu-submenu-type-stack" ><li id="menu-item-746" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-746 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-3 ubermenu-column ubermenu-column-auto" ><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><div id="mainMenuHeading"> <p id="mainMenuHeadingp">News & Resources</p> </div></div></li><li id="menu-item-742" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-742 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-3 ubermenu-column ubermenu-column-auto" ><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><div id="menu-itemN"> <p id="menu-headingN">News & Insights</p> <p id="menu-text">Stay up to date with the latest news and insights.</p> <p id="menu-btn"><a href="https://senahealth.com/press-industry-news/">News</a> </div> <div id="menu-itemN"> <p id="menu-headingN">News Blog</p> <p id="menu-text">Read the latest Sena Health news articles in our blog.</p> <p id="menu-btn"><a href="https://senahealth.com/sena-blog/">Our Blog</a> </div></div></li></ul></li><li class=" ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-has-children ubermenu-item-743 ubermenu-item-level-2 ubermenu-column ubermenu-column-1-3 ubermenu-has-submenu-stack ubermenu-item-type-column ubermenu-column-id-743"><ul class="ubermenu-submenu ubermenu-submenu-id-743 ubermenu-submenu-type-stack" ><li id="menu-item-745" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-745 ubermenu-item-auto ubermenu-item-normal ubermenu-item-level-3 ubermenu-column ubermenu-column-auto" ><div class="ubermenu-content-block ubermenu-custom-content ubermenu-custom-content-padded"><div id="menu-promo"> <img src="https://senahealth.com/wp-content/uploads/2022/10/senior-woman-on-video-call-receiving-care-at-home.jpg" width="100%"> <p id="promo-intro-heading">Case Study</p> <p id="promo-heading">Primary Care-Led Hospital at Home for Successful Aging in Place</p> <p id="promo-text">Our study focuses on enabling healing at home for a patient with exacerbation of chronic conditions by substituting hospital admissions with inpatient-level care at home from the primary care office, rather than a facility-based setting, to reduce the cost of care and support the patient and their physician in the ambulatory setting.</p> <span style="color:#8cb8c9"><a href="https://senahealth.com/wp-content/uploads/2022/11/HaH-Agile-and-Ready-Poster-2022.pdf" target="_blank">Download the Abstract</a></span> </div></div></li></ul></li></ul><ul class="ubermenu-row ubermenu-row-id-737 ubermenu-autoclear "><li class=" ubermenu-item ubermenu-item-type-custom ubermenu-item-object-ubermenu-custom ubermenu-item-has-children ubermenu-item-739 ubermenu-item-level-2 ubermenu-column ubermenu-column-1-3 ubermenu-has-submenu-stack ubermenu-item-type-column ubermenu-column-id-739"><ul class="ubermenu-submenu ubermenu-submenu-id-739 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class="elementor-element elementor-element-3e3fc96 elementor-widget elementor-widget-ubermenu" data-id="3e3fc96" data-element_type="widget" data-widget_type="ubermenu.default"> <div class="elementor-widget-container">  <a class="ubermenu-responsive-toggle ubermenu-responsive-toggle-main ubermenu-skin-vanilla ubermenu-loc- ubermenu-responsive-toggle-content-align-left ubermenu-responsive-toggle-align-full " tabindex="0" data-ubermenu-target="ubermenu-main-87"><i class="fas fa-bars" ></i>Menu</a><nav id="ubermenu-main-87" class="ubermenu ubermenu-nojs ubermenu-main ubermenu-menu-87 ubermenu-responsive ubermenu-responsive-default ubermenu-responsive-collapse ubermenu-horizontal ubermenu-transition-shift ubermenu-trigger-hover_intent ubermenu-skin-vanilla ubermenu-bar-align-right ubermenu-items-align-auto ubermenu-disable-submenu-scroll ubermenu-sub-indicators ubermenu-retractors-responsive ubermenu-submenu-indicator-closes"><ul id="ubermenu-nav-main-87" class="ubermenu-nav" data-title="Mobile"><li id="menu-item-1319" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-home ubermenu-item-1319 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="https://senahealth.com/" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Home</span></a></li><li id="menu-item-1333" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-item-1333 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-mega" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Who We Are</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-1333 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id="menu-item-1332" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-item-1332 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-mega" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Services</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-1332 ubermenu-submenu-type-auto ubermenu-submenu-type-mega ubermenu-submenu-drop ubermenu-submenu-align-full_width" ><li id="menu-item-1324" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1324 ubermenu-item-auto ubermenu-item-header ubermenu-item-level-1 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" 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ubermenu-target-text">Resources</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-1334 ubermenu-submenu-type-auto ubermenu-submenu-type-mega ubermenu-submenu-drop ubermenu-submenu-align-full_width" ><li id="menu-item-1320" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1320 ubermenu-item-auto ubermenu-item-header ubermenu-item-level-1 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="https://senahealth.com/sena-blog/"><span class="ubermenu-target-title ubermenu-target-text">Sena Blog</span></a></li><li id="menu-item-1328" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1328 ubermenu-item-auto ubermenu-item-header ubermenu-item-level-1 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" 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Use</span></a></li></ul></li><li id="menu-item-1335" class="ubermenu-item ubermenu-item-type-custom ubermenu-item-object-custom ubermenu-item-has-children ubermenu-item-1335 ubermenu-item-level-0 ubermenu-column ubermenu-column-auto ubermenu-has-submenu-drop ubermenu-has-submenu-mega" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" href="#" tabindex="0"><span class="ubermenu-target-title ubermenu-target-text">Contact</span><i class='ubermenu-sub-indicator fas fa-angle-down'></i></a><ul class="ubermenu-submenu ubermenu-submenu-id-1335 ubermenu-submenu-type-auto ubermenu-submenu-type-mega ubermenu-submenu-drop ubermenu-submenu-align-full_width" ><li id="menu-item-1323" class="ubermenu-item ubermenu-item-type-post_type ubermenu-item-object-page ubermenu-item-1323 ubermenu-item-auto ubermenu-item-header ubermenu-item-level-1 ubermenu-column ubermenu-column-auto" ><a class="ubermenu-target ubermenu-item-layout-default ubermenu-item-layout-text_only" 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.fc-form.fc-form-2 .form-element .field-cover input[type="email"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="password"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="tel"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover textarea, .formcraft-css .fc-form.fc-form-2 .form-element .field-cover select, .formcraft-css .fc-form.fc-form-2 .form-element .field-cover .time-fields-cover, .formcraft-css .fc-form.fc-form-2 .form-element .field-cover .awesomplete ul { color: #545454; } .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="text"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="password"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="email"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="radio"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="checkbox"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="tel"], .formcraft-css .fc-form.fc-form-2 .form-element .field-cover select, .formcraft-css .fc-form.fc-form-2 .form-element .field-cover textarea { background-color: #fafafa; } .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="radio"]:checked, .formcraft-css .fc-form.fc-form-2 .form-element .field-cover input[type="checkbox"]:checked { border-color: #7ba1b0; background: #8cb8c9; } .formcraft-css .fc-form.fc-form-2 .form-element .star-cover label .star { text-shadow: 0px 1px 0px #7ba1b0; } .formcraft-css .fc-form.fc-form-2 .form-element .slider-cover .ui-slider-range { box-shadow: 0px 1px 1px #7ba1b0 inset; } .formcraft-css .fc-form.fc-form-2 .form-element .fileupload-cover .button-file { border-color: #7ba1b0; } .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html input[type="password"]:focus, .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html input[type="email"]:focus, .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html input[type="tel"]:focus, .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html input[type="text"]:focus, .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html textarea:focus, .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html select:focus { border-color: #8cb8c9; } .formcraft-css .fc-form.fc-form-2 .form-element .form-element-html .field-cover .is-read-only:focus { border-color: #ccc; } .formcraft-css .fc-form.fc-form-2 { font-family: Helvetica, Arial, sans-serif; } @media (max-width : 480px) { html .dedicated-page, html .dedicated-page .formcraft-css .fc-pagination > div.active { background: url(https://3v5.01b.myftpupload.com/wp-content/plugins/formcraft3/views/../assets/images/backgrounds/coarse.png); } } </style> <div class="form-cover"> <form data-auto-scroll="" data-no-message-redirect="" data-thousand="" data-decimal="." data-delay="3" data-id="2" class="fc-form fc-form-2 align- fc-temp-class save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline field-border-visible frame-visible field-alignment-left " style="width: 1000px; color: #545454; font-size: 90%; background: url(https://3v5.01b.myftpupload.com/wp-content/plugins/formcraft3/views/../assets/images/backgrounds/coarse.png)"> <div class="form-page form-page-0" data-index="0"> <div class="form-page-content ng-not-empty"> <div data-identifier="field4" data-index="0" style="width: 100%" class=" form-element form-element-field4 options-false form-element-0 default-false form-element-type-customText is-required-false odd -handle"> <div class="form-element-html"><div ><div class="absolute-false customText-cover field-cover" style="left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:"><div class="full" style="text-align: left"><p ><img decoding="async" src="http://3v5.01b.myftpupload.com/wp-content/uploads/2020/11/logo-1.png" alt="Sena Logo" width="280" height="120" style="width: 280px; height: 120px"> </p></div><input type="hidden" name="field4" data-field-id="field4"></div></div></div> </div><div data-identifier="field2" data-index="1" style="width: 100%" class=" even form-element form-element-field2 options-false form-element-1 default-false form-element-type-heading is-required-false -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: center; font-size: 1.6em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Protected Health Information Access / Disposal Request Form</strong></div><input type="hidden" data-field-id="field2" name="field2[]" value="<strong>Protected Health Information Access / Disposal Request Form</strong>"></div></div></div> </div><div data-identifier="field6" data-index="2" style="width: 100%" class=" form-element form-element-field6 options-false form-element-2 default-false form-element-type-heading is-required-false odd -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: center; font-size: 1.4em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Instructions:</strong><span > Please complete the following form to request access to or disposal of Protected Health Information (PHI).</span></div><input type="hidden" data-field-id="field6" name="field6[]" value="<strong>Instructions:</strong> Please complete the following form to request access to or disposal of Protected Health Information (PHI)."></div></div></div> </div><div data-identifier="field9" data-index="3" style="width: 50%" class=" even form-element form-element-field9 options-false form-element-3 default-false form-element-type-checkbox is-required-true -handle"> <div class="form-element-html"><div ><div class="images- checkbox-cover field-cover"><span class="sub-label-false"><span class="main-label"><span >Request Type:</span></span><span class="sub-label"></span></span><div data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="hover" data-html="true" data-original-title=""><span class="error"></span><label style="width:" ><img alt=""><input data-field-id="field9" type="radio" data-is-required="true" name="field9[]" value="Access Request" class="validation-lenient"><span><span >Access Request</span></span></label><label style="width:" ><img alt=""><input data-field-id="field9" type="radio" data-is-required="true" name="field9[]" value="Disposal Request" class="validation-lenient"><span><span >Disposal Request</span></span></label></div></div></div></div> </div><div data-identifier="field10" data-index="4" style="width: 50%" class=" form-element form-element-field10 options-false form-element-4 default-false form-element-type-checkbox is-required-true odd -handle"> <div class="form-element-html"><div ><div class="images-false checkbox-cover field-cover"><span class="sub-label-false"><span class="main-label"><span >Requester Type:</span></span><span class="sub-label"></span></span><div data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="hover" data-html="true" data-original-title=""><span class="error"></span><label style="width:" ><img alt=""><input data-field-id="field10" type="radio" data-is-required="true" name="field10[]" value="Self" class="validation-lenient"><span><span >Self</span></span></label><label style="width:" ><img alt=""><input data-field-id="field10" type="radio" data-is-required="true" name="field10[]" value="Third Party" class="validation-lenient"><span><span >Third Party</span></span></label></div></div></div></div> </div><div data-identifier="field11" data-index="5" style="width: 100%" class=" even form-element form-element-field11 options-false form-element-5 default-false form-element-type-heading is-required-false -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: left; font-size: 1.4em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Personal Information (Requester):</strong></div><input type="hidden" data-field-id="field11" name="field11[]" value="<strong>Personal Information (Requester):</strong>"></div></div></div> </div><div data-identifier="field12" data-index="6" style="width: 100%" class=" form-element form-element-field12 options-false form-element-6 default-false form-element-type-oneLineText is-required-true odd -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-true"><span class="main-label"><span >Name</span></span><span class="sub-label"><span >your full name</span></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field12" name="field12[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field13" data-index="7" style="width: 100%" class=" even form-element form-element-field13 options-false form-element-7 default-false form-element-type-oneLineText is-required-true -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Your Relationship to Patient (” self” if you are the patient):</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field13" name="field13[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field14" data-index="8" style="width: 100%" class=" form-element form-element-field14 options-false form-element-8 default-false form-element-type-oneLineText is-required-true odd -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Patient's Full Name:</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field14" name="field14[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field15" data-index="9" style="width: 100%" class=" even form-element form-element-field15 options-false form-element-9 default-false form-element-type-oneLineText is-required-true -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Patient's Date of Birth:</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field15" name="field15[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field16" data-index="10" style="width: 100%" class=" form-element form-element-field16 options-false form-element-10 default-false form-element-type-heading is-required-false odd -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: left; font-size: 1.4em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Contact Information:</strong></div><input type="hidden" data-field-id="field16" name="field16[]" value="<strong>Contact Information:</strong>"></div></div></div> </div><div data-identifier="field17" data-index="11" style="width: 100%" class=" even form-element form-element-field17 options-false form-element-11 default-false form-element-type-oneLineText is-required-true -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Your Email:</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field17" name="field17[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field18" data-index="12" style="width: 100%" class=" form-element form-element-field18 options-false form-element-12 default-false form-element-type-oneLineText is-required-true odd -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Your Phone</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field18" name="field18[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field31" data-index="13" style="width: 100%" class=" even form-element form-element-field31 options-false form-element-13 default-false form-element-type-heading is-required-false -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: left; font-size: 1.4em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Verification Document (Upload):</strong></div><input type="hidden" data-field-id="field31" name="field31[]" value="<strong>Verification Document (Upload):</strong>"></div></div></div> </div><div data-identifier="field32" data-index="14" style="width: 100%" class=" form-element form-element-field32 options-false form-element-14 default-false form-element-type-customText is-required-false odd -handle"> <div class="form-element-html"><div ><div class="absolute-false customText-cover field-cover" style="left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:"><div class="full" style="text-align: left"><p ></p><p ><i><span style="font-size: 10.0pt">Upload a scanned copy of a government-issued ID or insurance card of the requester, and, if not the patient, a document verifying your relationship to the patient (e.g., birth certificate, power of attorney, legal authorization).</span></i></p><p ></p></div><input type="hidden" name="field32" value="Upload a scanned copy of a government-issued ID or insurance card of the requester, and, if not the patient, a document verifying your relationship to the patient (e.g., birth certificate, power of attorney, legal authorization)." data-field-id="field32"></div></div></div> </div><div data-identifier="field20" data-index="15" style="width: 100%" class=" even form-element form-element-field20 options-false form-element-15 default-false form-element-type-fileupload is-required-false -handle"> <div class="form-element-html"><div ><label class="wide- fileupload-cover field-cover"><span class="sub-label-"><span class="main-label"><span >File</span></span><span class="sub-label"><span >upload</span></span></span><div><span class="error"></span><div class="button button-file fileupload-button" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="hover" data-html="true" data-original-title=""><i class="icon-upload-cloud formcraft-icon">cloud_upload</i><span >Upload</span><input type="file" data-name-list="field20" name="files" multiple="multiple" data-allow-extensions="" data-min-files="" data-max-files="" data-max-size=""></div></div></label></div></div> </div><div data-identifier="field19" data-index="16" style="width: 100%" class=" form-element form-element-field19 options-false form-element-16 default-false form-element-type-heading is-required-false odd -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: left; font-size: 1.4em; padding-top: ; padding-bottom: ; color:" class="bold-"><strong >Request Details:</strong></div><input type="hidden" data-field-id="field19" name="field19[]" value="<strong>Request Details:</strong>"></div></div></div> </div><div data-identifier="field23" data-index="17" style="width: 100%" class=" even form-element form-element-field23 options-false form-element-17 default-false form-element-type-textarea is-required-false -handle"> <div class="form-element-html"><div ><label class="textarea-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Please provide a brief description of the information you are requesting access to or wish to have disposed:</span></span><span class="sub-label"></span></span><div><span class="error"></span><textarea data-field-id="field23" placeholder="" class="validation-lenient" name="field23" value="" rows="5" data-min-char="" data-max-char="" data-is-required="false" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-original-title="" style="min-height: 119.15px"></textarea><div class="count-"><span class="current-count">0</span> / <span class="max-count "></span></div></div></label></div></div> </div><div data-identifier="field30" data-index="18" style="width: 100%" class=" form-element form-element-field30 options-false form-element-18 default-false form-element-type-heading is-required-false odd -handle"> <div class="form-element-html"><div ><div style="background-color:" class="heading-cover field-cover "><div style="text-align: left; font-size: 1.0999999999999996em; padding-top: ; padding-bottom: ; color:" class="bold-"><span >I hereby request access to the Protected Health Information of the patient named above, or request disposal of specific PHI, as allowed by law.</span></div><input type="hidden" data-field-id="field30" name="field30[]" value="I hereby request access to the Protected Health Information of the patient named above, or request disposal of specific PHI, as allowed by law."></div></div></div> </div><div data-identifier="field25" data-index="19" style="width: 50%" class=" even form-element form-element-field25 options-false form-element-19 default-false form-element-type-oneLineText is-required-true -handle"> <div class="form-element-html"><div ><label class="oneLineText-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Signature</span></span><span class="sub-label"></span></span><div><span class="error"></span><input type="text" placeholder="" make-read-only="false" data-field-id="field25" name="field25[]" data-min-char="" data-max-char="" data-val-type="" data-regexp="" data-is-required="true" data-allow-spaces="true" class="validation-lenient" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-input-mask="" data-mask-placeholder="" data-original-title=""><i class="formcraft-icon formcraft-icon-type-"></i></div></label></div></div> </div><div data-identifier="field27" data-index="20" style="width: 50%" class=" form-element form-element-field27 options-false form-element-20 default-false form-element-type-datepicker is-required-true odd -handle"> <div class="form-element-html"><div ><label class="datepicker-cover field-cover "><span class="sub-label-false"><span class="main-label"><span >Date</span></span><span class="sub-label"></span></span><div><span class="error"></span><input autocomplete="off" data-field-id="field27" placeholder="" type="text" class="validation-lenient hasDatepicker ng-empty " data-is-required="true" datepicker="" data-date-min-range="" data-date-format="dd/mm/yy" data-date-days="{"0":true,"1":true,"2":true,"3":true,"4":true,"5":true,"6":true}" data-date-min="" data-date-min-alt="" data-date-max-alt="" data-date-max="" data-date-lang="en" name="field27" data-placement="right" data-toggle="tooltip" tooltip="" data-trigger="focus" data-html="true" data-original-title=""><i class="formcraft-icon">date_range</i></div></label></div></div> </div><div data-identifier="field28" data-index="21" style="width: 100%" class=" even form-element form-element-field28 options-false form-element-21 default-false form-element-type-customText is-required-false -handle"> <div class="form-element-html"><div ><div class="absolute-false customText-cover field-cover" style="left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:"><div class="full" style="text-align: left"><p ><b>Note: Your request will be processed according to applicable laws and regulations in no longer than 30 days from the date of receipt of completed form. 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