CINXE.COM
Patient Notebook
<!DOCTYPE html> <html> <head> <meta charset="utf-8" /> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <title>Patient Notebook</title> <link href="/bundles/single-column-layout-css?v=b_zrEBreTBOAAOaFGkJUsfVdlTY748LXScZGEi144Jk1" rel="stylesheet"/> <link href="/bundles/makepayment-css?v=NRMrKBa_8AjzLzGQ-Zx4Ppg9lkh2iIE4RCxgolFFHC01" rel="stylesheet"/> </head> <body> <div class="header-section"> <div class="header-container"> <div class="header-menu-wrapper"> <div class="header-menu-inner"> <div class="menu-label desktop">MENU</div> <div class="menu-label tablet"> <button id="btnLeftNavToggle" type="button" class="navbar-toggle"> MENU <span><i class="fa fa-bars fa-lg"></i></span> </button> </div> <div class="menu-label mobile"> <button id="btnLeftNavToggleMobile" type="button" class="navbar-toggle"> <i class="fa fa-bars fa-lg"></i> </button> </div> </div> </div> <div class="home-menu-wrapper"> <div class="col-xs-2 col-sm-2 col-md-3 col-lg-2 visible-lg visible-md visible-sm"> <a id="lnkPNHome" href="/Nufactor/Enhanced"> <img src="/Content/Images/PNLogo.png" alt="PatientNotebook" class="home-menu-img"/> </a> </div> </div> <div class="home-menu-wrapper"> <div class="col-xs-2 col-sm-2 col-md-3 col-lg-2 visible-xs"> <a id="lnkPNHomeMobile" href="/Nufactor/Enhanced"> <img src="/Content/Images/PN-small-symbol.png" alt="PatientNotebook" class="home-menu-img"/> </a> </div> </div> <div class="header-provider-wrapper"> <div class="provider-logo"> <div> <img alt="Logo" src="/Nufactor/Enhanced/SendMoney/ViewLogo" /> </div> </div> <div class="address-info"> <div class="cust-name">NuFactor, Inc.</div> <div class="cust-name">(800) 323-6832 x 1408</div> <div class="cust-street">44900 Winchester Road</div> <div class="cust-room"></div> <div class="cust-area">Temecula, CA 92590</div> </div> <div class="contact-info"> <div class="cust-email"> <span class="email-text">Email:</span> <a id="lnkProviderEmailHeader" href="mailto:NufactorStatements@nufactor.com">NufactorStatements@nufactor.com</a> </div> </div> <input id="ProviderName" name="ProviderName" type="hidden" value="Select a Provider" /> </div> </div> </div> <div class="body-container"> <form action="/Nufactor/Enhanced/SendMoney/PaymentConfirmation" id="MakePaymentForm" method="post"><input name="__RequestVerificationToken" type="hidden" value="RFE494fXFxEenBgHZp0QCXU09c-Ea-f9YuIgC6t9ouKLLzGOMXD-S3SuRHQugAYuTiD-1KCchmJn6Tpl8istx8n6Qzw1" /> <div class="make-payment-container"> <div class="payment-header"> Make a Payment </div> <div class="row"> <div class="payment-header-info payment-header-spacing col-lg-7"> Need to make a payment? Please fill out the information below and hit continue. </div> </div> <div class="validation-summary-container"> <div class="validation-summary-valid" data-valmsg-summary="true"> <div class="error"> <span><b>Error Summary</b></span> </div> <div class="panel-heading"> Please, correctly fill out all required fields. </div> <div class="panel-body"> <ul> </ul> </div> </div> </div> <div class="messages-container"> </div> <div class="patient-header"> 1. Patient Information </div> <div id="patient-details-container"> <div class="patient-details"> <div class="row first-name-group"> <div class="col-lg-7 col-md-7 col-xs-9"> <div class="form-group"> <label class="first-name-label" for="PatientFirstName">First Name</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-maxlength="First Name cannot exceed 50 characters." data-val-maxlength-max="50" data-val-requiredif="Patient First Name is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""ValidatePatientInformation && FormSettings.PatientName.Require"" data-val-requiredif-fieldsmap="{"ValidatePatientInformation":"bool","FormSettings.PatientName.Require":"bool"}" id="txtPatientFirstName" name="PatientFirstName" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="PatientFirstName" data-valmsg-replace="true"></span> </div> </div> <div class="col-lg-2 col-md-2 col-xs-3"> <div class="form-group"> <label class="mi-label" for="PatientMiddleInitial">M.I.</label> <input class="form-control" data-val="true" data-val-maxlength="Middle Initial cannot exceed 1 character." data-val-maxlength-max="1" data-val-regex="Middle initial not valid. Please enter a letter." data-val-regex-pattern="^[a-zA-Z]?$" id="txtPatientMiddleInitial" name="PatientMiddleInitial" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="PatientMiddleInitial" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row last-name-group"> <div class="col-lg-9 col-md-9 col-xs-11"> <div class="form-group"> <label class="last-name-label" for="PatientLastName">Last Name</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-maxlength="Last Name cannot exceed 50 characters." data-val-maxlength-max="50" data-val-requiredif="Patient Last Name is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""ValidatePatientInformation && FormSettings.PatientName.Require"" data-val-requiredif-fieldsmap="{"ValidatePatientInformation":"bool","FormSettings.PatientName.Require":"bool"}" id="txtPatientLastName" name="PatientLastName" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="PatientLastName" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row location-id-group"> <div class="col-lg-9 col-md-9 col-xs-11"> <div class="form-group"> <label class="location-id-label" for="InvoiceNumber">Contact Phone Number</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-maxlength="Invoice Number cannot exceed 50 characters." data-val-maxlength-max="50" data-val-requiredif="Invoice Number is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""ValidatePatientInformation && FormSettings.InvoiceNumber.Require"" data-val-requiredif-fieldsmap="{"ValidatePatientInformation":"bool","FormSettings.InvoiceNumber.Require":"bool"}" id="txtInvoiceNumber" name="InvoiceNumber" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="InvoiceNumber" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row email-group"> <div class="col-lg-9 col-md-9 col-xs-11"> <div class="form-group"> <label class="email-label" for="PatientEmail">Email Address</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-maxlength="Email cannot exceed 50 characters." data-val-maxlength-max="50" data-val-regex="Invalid email." data-val-regex-pattern="^([\w\.\-]+)@([\w\-]+\.)+(\w{2,})$" data-val-requiredif="Email Address is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""ValidatePatientInformation && FormSettings.Email.Require"" data-val-requiredif-fieldsmap="{"ValidatePatientInformation":"bool","FormSettings.Email.Require":"bool"}" id="txtPatientEmail" name="PatientEmail" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="PatientEmail" data-valmsg-replace="true"></span> </div> <div class="info-text"> A receipt will be sent to this email address. </div> </div> </div> <input data-val="true" data-val-required="The UseDefaultPatientInformation field is required." id="UseDefaultPatientInformation" name="UseDefaultPatientInformation" type="hidden" value="False" /> </div> </div> <div class="payment-amount-header"> 2. Payment Amount </div> <div id="payment-amount-container"> <div class="payment-amount-container"> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group payment-amount-input-container"> <label class="payment-amount-input-label" for="PaymentAmount">Amount</label> <span class="fa fa-dollar payment-amount-input-symbol"></span> <input class="form-control payment-amount-input-text" data-val="true" data-val-assertthat="Payment Amount must be greater than $0.00" data-val-assertthat-expression=""IsGreaterThan(PaymentAmount, '0')"" data-val-assertthat-fieldsmap="{"PaymentAmount":"string"}" data-val-assertthat-methodslist="["IsGreaterThan"]" data-val-requiredif="Amount is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentType == 1"" data-val-requiredif-fieldsmap="{"PaymentType":"number"}" id="txtPaymentAmount" name="PaymentAmount" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="PaymentAmount" data-valmsg-replace="true"></span> </div> <div class="info-text"> This payment will be issued to NuFACTOR a Specialty Home Infusion Company </div> </div> </div> </div> </div> <div class="payment-details-header"> 3. Payment Method </div> <div id="payment-details-container"> <div class="payment-details"> <div class="row payment-method-type"> <div id="tabCardPayment" class="col-lg-6 col-md-6 col-xs-6 card-payment active first"> Credit/Debit Card </div> <div id="tabBankPayment" class="col-lg-6 col-md-6 col-xs-6 bank-payment "> Bank Account </div> </div> <div class="card-payment-container payment-container"> <div class="row"> <div class="col-lg-9 col-md-9 col-xs-11"> <div class="form-group"> <label class="name-on-card-label" for="CCNameOnCard">Name on Card</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-maxlength="Name on Card cannot exceed 22 characters." data-val-maxlength-max="22" data-val-requiredif="Name on Card is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""FormSettings.CardName.Require && PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"FormSettings.CardName.Require":"bool","PaymentMethod":"number"}" id="txtCCNameOnCard" name="CCNameOnCard" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="CCNameOnCard" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group"> <label class="card-number-label" for="CCNumber">Card Number</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-minlength="Invalid Credit Card Number" data-val-minlength-min="4" data-val-requiredif="Credit Card Number is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="txtCCNumber" name="CCNumber" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="CCNumber" data-valmsg-replace="true" id="CCNumber_Validation"></span> <div class="cards-logos"> <i class="fa fa-cc-visa fa-2x"></i> <i class="fa fa-cc-mastercard fa-2x"></i> <i class="fa fa-cc-discover fa-2x"></i> <i class="fa fa-cc-amex fa-2x"></i> </div> </div> </div> </div> <div class="exp-sec-row"> <div class="expiration-date-container"> <label>Expiration Date</label> <span class="requiredFieldLabelStar"> *</span> <div class="exp-input-container"> <div class="exp-month-container"> <div class="wrapper-dropdown" id="ddlCCMonth" tabindex="0"> <div class="dropdown-text-wrapper"> <span data-id="-1" class="dropdown-text"> MM </span> </div> <input data-val="true" data-val-assertthat="Please enter a valid credit card expiration date." data-val-assertthat-expression=""IsValidCardExpirationDate(CCMonth, CCYear)"" data-val-assertthat-fieldsmap="{"CCMonth":"number","CCYear":"number"}" data-val-assertthat-methodslist="["IsValidCardExpirationDate"]" data-val-number="The field Exp Month must be a number." data-val-requiredif="Credit Card Expiration Month is Required" data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="CCMonth" name="CCMonth" type="hidden" value="" /> <i class="fa fa-chevron-down fa-xs dropdown-arrow"></i> <ul class="dropdown"> <li tabindex="-1" data-month="" class="">--</li> <li tabindex="-1" data-month="1" class="">01</li> <li tabindex="-1" data-month="2" class="">02</li> <li tabindex="-1" data-month="3" class="">03</li> <li tabindex="-1" data-month="4" class="">04</li> <li tabindex="-1" data-month="5" class="">05</li> <li tabindex="-1" data-month="6" class="">06</li> <li tabindex="-1" data-month="7" class="">07</li> <li tabindex="-1" data-month="8" class="">08</li> <li tabindex="-1" data-month="9" class="">09</li> <li tabindex="-1" data-month="10" class="">10</li> <li tabindex="-1" data-month="11" class="">11</li> <li tabindex="-1" data-month="12" class="">12</li> </ul> </div> </div> <div class="exp-year-container"> <div class="wrapper-dropdown" id="ddlCCYear" tabindex="0"> <div class="dropdown-text-wrapper"> <span data-id="-1" class="dropdown-text"> YYYY </span> </div> <input data-val="true" data-val-number="The field Exp Year must be a number." data-val-requiredif="Credit Card Expiration Year is Required" data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="CCYear" name="CCYear" type="hidden" value="" /> <i class="fa fa-chevron-down fa-xs dropdown-arrow"></i> <ul class="dropdown"> <li tabindex="-1" data-year="" class="">--</li> <li tabindex="-1" data-year="24" class="">2024</li> <li tabindex="-1" data-year="25" class="">2025</li> <li tabindex="-1" data-year="26" class="">2026</li> <li tabindex="-1" data-year="27" class="">2027</li> <li tabindex="-1" data-year="28" class="">2028</li> <li tabindex="-1" data-year="29" class="">2029</li> <li tabindex="-1" data-year="30" class="">2030</li> <li tabindex="-1" data-year="31" class="">2031</li> <li tabindex="-1" data-year="32" class="">2032</li> <li tabindex="-1" data-year="33" class="">2033</li> <li tabindex="-1" data-year="34" class="">2034</li> <li tabindex="-1" data-year="35" class="">2035</li> <li tabindex="-1" data-year="36" class="">2036</li> <li tabindex="-1" data-year="37" class="">2037</li> <li tabindex="-1" data-year="38" class="">2038</li> <li tabindex="-1" data-year="39" class="">2039</li> <li tabindex="-1" data-year="40" class="">2040</li> <li tabindex="-1" data-year="41" class="">2041</li> <li tabindex="-1" data-year="42" class="">2042</li> <li tabindex="-1" data-year="43" class="">2043</li> <li tabindex="-1" data-year="44" class="">2044</li> <li tabindex="-1" data-year="45" class="">2045</li> <li tabindex="-1" data-year="46" class="">2046</li> <li tabindex="-1" data-year="47" class="">2047</li> <li tabindex="-1" data-year="48" class="">2048</li> <li tabindex="-1" data-year="49" class="">2049</li> <li tabindex="-1" data-year="50" class="">2050</li> <li tabindex="-1" data-year="51" class="">2051</li> <li tabindex="-1" data-year="52" class="">2052</li> <li tabindex="-1" data-year="53" class="">2053</li> </ul> </div> </div> </div> <span class="field-validation-valid val-error" data-valmsg-for="CCMonth" data-valmsg-replace="true"></span> <br /> <span class="field-validation-valid val-error" data-valmsg-for="CCYear" data-valmsg-replace="true"></span> </div> <div class="sec-code-container"> <label class="sec-code-label" for="CCSecCode">Security Code</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control sec-code" data-val="true" data-val-range="Please enter a valid Security Code." data-val-range-max="9999" data-val-range-min="0" data-val-requiredif="Security Code is Required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""FormSettings.SecurityCode.Require && PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"FormSettings.SecurityCode.Require":"bool","PaymentMethod":"number"}" id="txtCCSecCode" name="CCSecCode" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="CCSecCode" data-valmsg-replace="true"></span> </div> </div> <div class="zip-container"> <div class="form-group"> <label class="zip-code-label" for="CCZipCode">Zip Code</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-regex="Please enter a valid Zip Code." data-val-regex-pattern="^\d{5}(?:[-\s]\d{4})?$" data-val-requiredif="Billing Zip Code is required" data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 1"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="txtCCZipCode" name="CCZipCode" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="CCZipCode" data-valmsg-replace="true"></span> </div> </div> </div> <div class="bank-payment-container hidden"> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group account-type"> <label class="account-type-label" for="BAAccountType">Account Type</label> <br /> <input Checked="checked" data-val="true" data-val-number="The field Account Type must be a number." data-val-required="The Account Type field is required." id="rbAccountType_Checking" name="BAAccountType" type="radio" value="1" /> <label class="account-type-select-label" for="rbAccountType_Checking">Checking</label> <input id="rbAccountType_Savings" name="BAAccountType" type="radio" value="2" /> <label class="account-type-select-label" for="rbAccountType_Savings">Savings</label> </div> </div> </div> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group"> <label class="routing-number-label" for="BARouting">Routing Number</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-assertthat="Please enter a valid Routing Number." data-val-assertthat-expression=""IsValidRoutingNumber(BARouting)"" data-val-assertthat-fieldsmap="{"BARouting":"string"}" data-val-assertthat-methodslist="["IsValidRoutingNumber"]" data-val-requiredif="Routing Number is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 4"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="txtBARoutingNumber" maxlength="9" name="BARouting" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="BARouting" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group"> <label class="account-number-label" for="BAAccount">Account Number</label> <span class="requiredFieldLabelStar"> *</span> <input class="form-control" data-val="true" data-val-regex="Please enter a valid Account Number." data-val-regex-pattern="^((([xX]){3,13}([0-9]){0,14})|([0-9]){3,17})$" data-val-requiredif="Account Number is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 4"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number"}" id="txtBAAccountNumber" name="BAAccount" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="BAAccount" data-valmsg-replace="true"></span> </div> </div> </div> <div class="check-information-container"> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group"> <label class="name-on-check-label" for="BANameOnCheck">Name On Check</label> <input class="form-control" data-val="true" data-val-maxlength="Name on Check cannot exceed 100 characters." data-val-maxlength-max="100" data-val-requiredif="Name on Check is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 4 && BAAccountType < 2 && FormSettings.ACHSettings.PaymentRouteId == 9"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number","BAAccountType":"number","FormSettings.ACHSettings.PaymentRouteId":"number"}" id="ACHNameOnCheck" name="BANameOnCheck" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="BANameOnCheck" data-valmsg-replace="true"></span> </div> </div> </div> <div class="row"> <div class="col-lg-5 col-md-5 col-xs-11"> <div class="form-group"> <label class="check-number-label" for="BACheckNumber">Check Number</label> <input class="form-control" data-val="true" data-val-maxlength="Check Number cannot exceed 25 characters." data-val-maxlength-max="25" data-val-regex="Invalid check number" data-val-regex-pattern="^[0-9]+$" data-val-requiredif="Check Number is required." data-val-requiredif-allowempty="false" data-val-requiredif-expression=""PaymentMethod == 4 && BAAccountType < 2 && FormSettings.ACHSettings.PaymentRouteId == 9"" data-val-requiredif-fieldsmap="{"PaymentMethod":"number","BAAccountType":"number","FormSettings.ACHSettings.PaymentRouteId":"number"}" id="ACHCheckNumber" name="BACheckNumber" type="text" value="" /> <span class="field-validation-valid val-error" data-valmsg-for="BACheckNumber" data-valmsg-replace="true"></span> </div> </div> </div> </div> </div> <div class="hidden"> <input Value="1" data-val="true" data-val-assertthat="Payment Method is Required" data-val-assertthat-expression=""PaymentMethod != 0"" data-val-assertthat-fieldsmap="{"PaymentMethod":"number"}" data-val-number="The field Payment Method must be a number." data-val-required="The Payment Method field is required." id="PaymentMethod" name="PaymentMethod" type="hidden" value="0" /> </div> </div> </div> <div class="row submit-payment-section"> <div class="col-lg-3 col-md-3 col-sm-3 col-xs-5"> <button type="button" id="makePaymentSubmit" class="btn btn-primary">Continue</button> </div> <div id="linkMakePaymentCancel" class="col-lg-1 col-md-1 col-xs-2 cancel-link"> Cancel </div> </div> <div id="FormSettings" class="hidden"> <input data-val="true" data-val-number="The field PaymentRouteId must be a number." data-val-required="The PaymentRouteId field is required." id="FormSettings_ACHSettings_PaymentRouteId" name="FormSettings.ACHSettings.PaymentRouteId" type="hidden" value="3" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_CardName_Require" name="FormSettings.CardName.Require" type="hidden" value="True" /> <input data-val="true" data-val-number="The field PaymentRouteId must be a number." data-val-required="The PaymentRouteId field is required." id="FormSettings_CCSettings_PaymentRouteId" name="FormSettings.CCSettings.PaymentRouteId" type="hidden" value="1" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_DateOfService_Require" name="FormSettings.DateOfService.Require" type="hidden" value="False" /> <input data-val="true" data-val-required="The DisplaySingleDateOfService field is required." id="FormSettings_DisplaySingleDateOfService" name="FormSettings.DisplaySingleDateOfService" type="hidden" value="False" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_Email_Require" name="FormSettings.Email.Require" type="hidden" value="True" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_InvoiceDate_Require" name="FormSettings.InvoiceDate.Require" type="hidden" value="False" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_InvoiceNumber_Require" name="FormSettings.InvoiceNumber.Require" type="hidden" value="True" /> <input id="FormSettings_PANFailText" name="FormSettings.PANFailText" type="hidden" value="Patient Account Number is invalid." /> <input id="FormSettings_PANRegex" name="FormSettings.PANRegex" type="hidden" value="" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_PatientAccountNumber_Require" name="FormSettings.PatientAccountNumber.Require" type="hidden" value="False" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_PatientName_Require" name="FormSettings.PatientName.Require" type="hidden" value="True" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_SecurityCode_Require" name="FormSettings.SecurityCode.Require" type="hidden" value="True" /> <input data-val="true" data-val-required="The Require field is required." id="FormSettings_VisitNumber_Require" name="FormSettings.VisitNumber.Require" type="hidden" value="False" /> <input data-val="true" data-val-required="The ValidatePatientInformation field is required." id="ValidatePatientInformation" name="ValidatePatientInformation" type="hidden" value="True" /> </div> <input id="Controller" name="Controller" type="hidden" value="SendMoney" /> <input data-val="true" data-val-number="The field Payment Type must be a number." data-val-required="The Payment Type field is required." id="PaymentType" name="PaymentType" type="hidden" value="1" /> </div> </form> </div> <div class="footer-container" id="footer-container"> <div class="hidden-lg"> <div class="footer-info-container"> <button id="btnShowProviderInfo" class="fa fa-info-circle info-button" data-toggle="collapse" href="#collapseOne"></button> <span class="tablet-name">NuFactor, Inc.</span> </div> <div id="collapseOne" class="panel-collapse collapse tablet-contact-info"> <p>(800) 323-6832 x 1408</p> <p>E <a id="lnkProviderEmailFooter" class="tablet-email" href="mailto:NufactorStatements@nufactor.com">NufactorStatements@nufactor.com</a></p> <span class="mobile-street">44900 Winchester Road </span> <p><span class="mobile-area">Temecula, CA 92590</span></p> </div> </div> <p class="copy-right">Copyright 2024 Waystar All rights reserved. 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