providerforms.uhc.com
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Submitted URL: http://providerforms.uhc.com/chartdrop.html
Effective URL: https://providerforms.uhc.com/chartdrop.html
Submission: On February 19 via manual from US — Scanned from DE
Effective URL: https://providerforms.uhc.com/chartdrop.html
Submission: On February 19 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
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Attachment details
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Review and submit
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<p>For health care professionals of Quality Program File Submissions</p>
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<h2 style="font-size: 13.0pt;"><b>Estimated time to complete:</b></h2>
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<div class="guideimage guide-1617104033224">
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<p><b>5 - 10 minutes</b></p>
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</div>
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<ul>
<li>This form is for health care professionals who are submitting medical records to fulfill HEDIS ® and quality program requests</li>
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<h2 style="font-size: 13.0pt;"><b>What do I need?</b></h2>
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</div>
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<div id="guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_205188_1513943985___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0"
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<p>To complete this submission, you may be required to provide some or all of the information:</p>
<ul>
<li>Group name</li>
<li>Contact first and last name</li>
<li>Return phone number in case there are questions or issues with the submission</li>
<li>Reference # provided on the medical record request list</li>
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<h2 style="font-size: 13.0pt;"><b>Important things to know before completing the form</b></h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_2078509262___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12"
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<ul>
<li>Name medical records using the reference # on the medical record request list (example reference # 44458135553)</li>
<li>Files must be in either PDF, TIFF, or TIF format only. No other formats are accepted. The system will give you a real-time notification if the format of the uploaded document(s) is
unacceptable.</li>
<li>Do not submit password protected documents. This is a secure site and there is no need for additional security measures.</li>
</ul>
</div>
</div>
</div>
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<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel-guidetextbox_1972929259___widget" id="guideContainer-rootPanel-panel-guidetextbox_1972929259___label">Form UID</label></div>
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<div class="guideFieldNode guideTextBox FormType noSummary defaultFieldLayout af-field-filled" id="guideContainer-rootPanel-panel-guidetextbox_1620434552__"
data-guide-view-bind="guideContainer-rootPanel-panel-guidetextbox_1620434552__" style="" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel-guidetextbox_1620434552___widget" id="guideContainer-rootPanel-panel-guidetextbox_1620434552___label">FormType</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel-guidetextbox_1620434552___widget" name="guideContainer-rootPanel-panel-guidetextbox_1620434552___jqName" value="Provider"
style="position: relative;" placeholder="" aria-describedby="guideContainer-rootPanel-panel-guidetextbox_1620434552___widget_desc" tabindex="0" aria-label="FormType">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel-guidetextbox_1620434552___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel-guidetextbox_7273503___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden" data-guide-parent-id="guideContainer-rootPanel-panel__">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox FormName noSummary defaultFieldLayout af-field-filled" id="guideContainer-rootPanel-panel-guidetextbox_7273503__"
data-guide-view-bind="guideContainer-rootPanel-panel-guidetextbox_7273503__" style="" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel-guidetextbox_7273503___widget" id="guideContainer-rootPanel-panel-guidetextbox_7273503___label">FormName</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel-guidetextbox_7273503___widget" name="guideContainer-rootPanel-panel-guidetextbox_7273503___jqName"
value="Quality Programs Web Submission - Chart Drop Form" style="position: relative;" placeholder="" aria-describedby="guideContainer-rootPanel-panel-guidetextbox_7273503___widget_desc" tabindex="0"
aria-label="FormName">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel-guidetextbox_7273503___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel-guidetextbox___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden" data-guide-parent-id="guideContainer-rootPanel-panel__">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox fdmPath noSummary defaultFieldLayout af-field-filled" id="guideContainer-rootPanel-panel-guidetextbox__" data-guide-view-bind="guideContainer-rootPanel-panel-guidetextbox__"
style="" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel-guidetextbox___widget" id="guideContainer-rootPanel-panel-guidetextbox___label">fdmPath</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel-guidetextbox___widget" name="guideContainer-rootPanel-panel-guidetextbox___jqName"
value="/content/dam/formsanddocuments-fdm/uhc/sharedservices/dfa/dfa-fields" style="position: relative;" placeholder="" aria-describedby="guideContainer-rootPanel-panel-guidetextbox___widget_desc" tabindex="0"
aria-label="fdmPath">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Form Instructions">
</div>
</div>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792___guide-item" class="fd-col-lg-26 fd-col-lg-offset-0 fd-col-md-26 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0 hidden"
data-guide-parent-id="guideContainer-rootPanel__">
<div class="panel guide-1698403566468">
<div class="guidePanelNode wizardPanel noSummary" id="guideContainer-rootPanel-panel1617372512792__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792" style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792__">
<div class="dfa-wizard wizard">
<div id="guideContainer-rootPanel-panel1617372512792___layoutContainer" class="guideLayout row guideWizardLayout" style="position:relative;">
<div class="col-md-12 clearfix">
<div class="col-md-1 col-sm-1 hidden-xs">
</div>
<div class="col-md-10 col-sm-10">
<ol id="guideContainer-rootPanel-panel1617372512792___guide-item-nav-container" class="wizard-navigators hidden-xs" data-guide-panel-edit="reorderItems" role="tablist">
<div id="im_guideContainer-rootPanel-panel1617372512792-panel1636721920885__" style="display: none" data-guide-template-marker="true"></div>
<li id="guideContainer-rootPanel-panel1617372512792-panel1636721920885___guide-item-nav" title="Email verification"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636721920885" role="tab"
aria-controls="guideContainer-rootPanel-panel1617372512792-panel1636721920885___guide-item" class="af-widget-itemnav af-widget-itemnav-4 active" data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__"
aria-selected="true" aria-disabled="false">
<a class=" guideNavIcon" role="link" tabindex="-1">
<span data-guide-prop="title" data-guide-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">Email verification</span>
</a>
<div class="progress">
<div class="progress-bar progress-bar-warning" role="progressbar" aria-valuenow="0" aria-valuemin="0" aria-valuemax="100" style="width: 0%;">
<span class="sr-only">0% Complete</span>
</div>
</div>
<div class="indicator"></div>
</li>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel1636959977423__" style="display: none" data-guide-template-marker="true"></div>
<li id="guideContainer-rootPanel-panel1617372512792-panel1636959977423___guide-item-nav" title="Provider information"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636959977423" role="tab"
aria-controls="guideContainer-rootPanel-panel1617372512792-panel1636959977423___guide-item" class="af-widget-itemnav af-widget-itemnav-4" data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__"
aria-selected="false">
<a class=" guideNavIcon" role="link" tabindex="-1">
<span data-guide-prop="title" data-guide-id="guideContainer-rootPanel-panel1617372512792-panel1636959977423__">Provider information</span>
</a>
<div class="progress">
<div class="progress-bar progress-bar-warning" role="progressbar" aria-valuenow="0" aria-valuemin="0" aria-valuemax="100" style="width: 0%;">
<span class="sr-only">0% Complete</span>
</div>
</div>
<div class="indicator"></div>
</li>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop__" style="display: none" data-guide-template-marker="true"></div>
<li id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop___guide-item-nav" title="Attachment details"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop" role="tab"
aria-controls="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop___guide-item" class="af-widget-itemnav af-widget-itemnav-4" data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__"
aria-selected="false">
<a class=" guideNavIcon" role="link" tabindex="-1">
<span data-guide-prop="title" data-guide-id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop__">Attachment details</span>
</a>
<div class="progress">
<div class="progress-bar progress-bar-warning" role="progressbar" aria-valuenow="0" aria-valuemin="0" aria-valuemax="100" style="width: 0%;">
<span class="sr-only">0% Complete</span>
</div>
</div>
<div class="indicator"></div>
</li>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel__" style="display: none" data-guide-template-marker="true"></div>
<li id="guideContainer-rootPanel-panel1617372512792-panel___guide-item-nav" title="Review and submit"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel" role="tab"
aria-controls="guideContainer-rootPanel-panel1617372512792-panel___guide-item" class="af-widget-itemnav af-widget-itemnav-4" data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__" aria-selected="false">
<a class="noSummary_nav guideNavIcon" role="link" tabindex="-1">
<span data-guide-prop="title" data-guide-id="guideContainer-rootPanel-panel1617372512792-panel__">Review and submit</span>
</a>
<div class="progress">
<div class="progress-bar progress-bar-warning" role="progressbar" aria-valuenow="0" aria-valuemin="0" aria-valuemax="100" style="width: 0%;">
<span class="sr-only">0% Complete</span>
</div>
</div>
<div class="indicator"></div>
</li>
</ol>
</div>
<div class="col-md-1 col-sm-1 hidden-xs">
</div>
</div>
<div id="#guideContainer-rootPanel-panel1617372512792___layoutPanelContainer" class="col-md-10 col-sm-10 PanelContainer afWizardPanel">
<div id="guideContainer-rootPanel-panel1617372512792___guide-item-container">
<div id="im_guideContainer-rootPanel-panel1617372512792-panel1636721920885__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885___guide-item" role="tabpanel" aria-labelledby="guideContainer-rootPanel-panel1617372512792-panel1636721920885___guide-item-nav"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__" class="active">
<div class="panel1636721920885 panel">
<div class="guidePanelNode EmailVerification " id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636721920885" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_134855___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 active"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextdraw guidefield guide-1624350408214">
<div class="guideFieldNode guideTextDraw EmailVerification guideStaticText af-field-filled" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_134855__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_134855__" data-disabled="false">
<h2 style="font-size: 26.0px;">Email verification</h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextdraw guidefield guide-1636121031774">
<div class="guideFieldNode guideTextDraw textdraw_7146535451625727548162 noSummary guideStaticText af-field-filled" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw__"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw__" data-disabled="false">
<p>All fields are required</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_144278___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextdraw guidefield guide-1636119542149">
<div class="guideFieldNode guideTextDraw textdraw_3349913611618840062843 guideStaticText af-field-filled" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_144278__"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_144278__" data-disabled="false">
<p><b>Let's verify your contact information</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_391402___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextdraw guidefield guide-1636119675383">
<div class="guideFieldNode guideTextDraw VerifyTxt noSummary guideStaticText af-field-filled" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_391402__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_391402__" data-disabled="false">
<p>Please enter your email address and select Send code. A code will be sent to the email address entered to verify the address is valid. If you don’t get the email, make sure the address you entered is
correct or check your spam folder.</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___guide-item"
class="fd-col-lg-8 fd-col-lg-offset-0 fd-col-md-8 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guideemail guidetextbox guidefield guide-1636122464378">
<div class="guideFieldNode guideTextBox Youremailaddress defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail__" style="" data-mandatory="true" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___label">Enter email address (name@domain.com) *</label></div>
<div class="guideFieldWidget textField guideEmail" data-original-title="" title="">
<input type="email" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___widget" autocomplete="email"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___jqName" aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___widget_desc"
tabindex="0" aria-label="Enter email address (name@domain.com) *" aria-required="true" placeholder="" style="position: relative;">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guideemail___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidebutton guidefield guide-1637819974985">
<div class="guideFieldNode guideButton SendCode defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton__" style="" data-disabled="false">
<div class="guideFieldWidget guideFieldButtonWidget xfaButton" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton___jqName" style="position: relative;" tabindex="0" aria-label="Send code" placeholder="" data-original-title=""
title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Send code</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox response defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox__" style="" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___label">response</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___jqName" style="position: relative;" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___widget_desc" tabindex="0" aria-label="response">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_203692___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidetextdraw guidefield guide-1636119692849">
<div class="guideFieldNode guideTextDraw TxtCode noSummary guideStaticText af-field-filled" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_203692__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidetextdraw_203692__" data-disabled="false">
<p>Code sent. Please check your email for the code and enter it below.</p>
<p>Code expires after 6 hours and can only be utilized once.</p>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="panel">
<div class="guidePanelNode ValidationPanel noSummary" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636721920885/items/panel1635922949691" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___guide-item"
class="fd-col-lg-8 fd-col-lg-offset-0 fd-col-md-8 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0 active"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__">
<div class="guidetextbox guidefield guide-1636122478693">
<div class="guideFieldNode guideTextBox Code defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937__" style="" data-mandatory="true" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___label">Enter code *</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___jqName" style="position: relative;" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___widget_desc" tabindex="0" aria-label="Enter code *"
aria-required="true">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton___guide-item"
class="fd-col-lg-3 fd-col-lg-offset-0 fd-col-md-3 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__">
<div class="guidebutton guidefield guide-1637820034246">
<div class="guideFieldNode guideButton ValidateCode noSummary defaultFieldLayout af-field-empty"
id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton__" style="" data-disabled="false">
<div class="guideFieldWidget guideFieldButtonWidget xfaButton" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton___jqName" style="position: relative;" tabindex="0" aria-label="Validate code"
placeholder="" data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Validate code</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12 hidden"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691__">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox ValidateRespone defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox__" style="" data-disabled="false">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___label">validateresponse</label></div>
<div class="guideFieldWidget textField" style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___jqName" style="position: relative;" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___widget_desc" tabindex="0" aria-label="validateresponse">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - ValidationPanel">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839___guide-item"
class="fd-col-lg-2 fd-col-lg-offset-0 fd-lg-newline fd-col-md-2 fd-col-md-offset-0 fd-md-newline fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidebutton guidefield guide-1637819920851">
<div class="guideFieldNode guideButton BackVerification defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839__" style="" data-disabled="false">
<div class="guideFieldWidget guideFieldButtonWidget xfaButton" style="" data-original-title="" title="">
<button class="button-default button-medium movePrev" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839___jqName" style="position: relative;" tabindex="0" aria-label="Back" placeholder="" data-original-title=""
title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Back</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_34575839___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186___guide-item"
class="fd-col-lg-2 fd-col-lg-offset-0 fd-col-md-2 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0 hidden"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792-panel1636721920885__">
<div class="guidebutton guidefield guide-1698318544801">
<div class="guideFieldNode guideButton NxtButtonveri noSummary defaultFieldLayout af-field-empty" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186__" style="" data-disabled="false">
<div class="guideFieldWidget guideFieldButtonWidget xfaButton" style="" data-original-title="" title="">
<button class="button-default button-medium moveNext" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186___widget"
name="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186___jqName" style="position: relative;" tabindex="0" aria-label="Next" placeholder="" data-original-title=""
title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Next</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636721920885-guidebutton_11198186___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Email verification">
</div>
</div>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel1636959977423__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423___guide-item" role="tabpanel" aria-labelledby="guideContainer-rootPanel-panel1617372512792-panel1636959977423___guide-item-nav"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__">
<div class="panel1636959977423 panel">
<div class="guidePanelNode ProviderInformation " id="guideContainer-rootPanel-panel1617372512792-panel1636959977423__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636959977423" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-dfaheadertext___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield guide-1638276867853">
<div class="guideFieldNode guideTextDraw headertext noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-dfaheadertext__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-dfaheadertext__">
<h2 style="font-size: 26.0px;">Provider information</h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextdraw___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield guide-1696577567675">
<div class="guideFieldNode guideTextDraw textdraw1638278004382 noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextdraw__">
<p>Fields marked with an asterisk * are required.</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextbox guidefield guide-1631217204084">
<div class="guideFieldNode guideTextBox groupName
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___label">Group name *</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___widget" name="groupName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___widget_desc">
</div>
<div class="guideHelpQuestionMark" data-guide-longdescription="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___guideFieldLongDescription"
data-guide-alwaysshow="false" tabindex="0" aria-label="Help Content">
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___guideFieldLongDescription" class="guideFieldDescription long" style="">
<p style="color: rgb(17,17,17);">Enter provider group of physician who provided the service (examples: Mayo Clinic, LabCorp, Primary Medical Group (PMG), Rite-Aid, CareMount Medical)</p>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_381868123___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextbox guidefield guide-1631217259591">
<div class="guideFieldNode guideTextBox providerFirstName
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___label">Contact first name *</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___widget" name="providerFirstName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_4133143___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextbox guidefield guide-1631217262070">
<div class="guideFieldNode guideTextBox providerLastName
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___label">Contact last name *</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___widget" name="providerLastName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3120050___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextbox guidefield guide-1637086307760">
<div class="guideFieldNode guideTextBox phoneNumber
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___label">Phone number *</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___widget" name="phoneNumber" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_3176597___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextbox guidefield guide-1631217263740">
<div class="guideFieldNode guideTextBox commentsTxt
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___widget"
id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___label">Comments</label></div>
<div class="guideFieldWidget textField multiline " style="" data-original-title="" title="">
<textarea id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___widget" autocomplete="off" name="commentsTxt" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___widget_desc"></textarea>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-guidetextbox_2466703___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-previtemnav___guide-item"
class="fd-col-lg-2 fd-col-lg-offset-0 fd-lg-newline fd-col-md-2 fd-col-md-offset-0 fd-md-newline fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="previtemnav guidebutton guidefield guide-1637821927540">
<div class="guideFieldNode guideButton previtemnav1636960621897
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-previtemnav__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-previtemnav__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium movePrev" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-previtemnav___widget" name="previtemnav1636960621897" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Back</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-previtemnav___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-nextitemnav___guide-item"
class="fd-col-lg-3 fd-col-lg-offset-0 fd-col-md-3 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="nextitemnav guidebutton guidefield guide-1637821946165">
<div class="guideFieldNode guideButton nextitemnav1636960639799
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-nextitemnav__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel1636959977423-nextitemnav__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium moveNext" type="button" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-nextitemnav___widget" name="nextitemnav1636960639799" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Next</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel1636959977423-nextitemnav___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Provider information">
</div>
</div>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop___guide-item" role="tabpanel" aria-labelledby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop___guide-item-nav"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__">
<div class="panel_1492325676_cop panel">
<div class="guidePanelNode qestion " id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1299286511___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637060577592">
<div class="guideFieldNode guideTextDraw Attachmentdetails noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1299286511__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1299286511__">
<h2 style="font-size: 26.0px;"><b>Attachment details</b></h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826264696">
<div class="guideFieldNode guideTextDraw textdraw1636960905473 noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw__">
<p>Documents should only be attached for members included in the request package received from Quality Value Solutions Delivery for HEDIS® and other quality programs.</p>
<p><u>Document Requirements:</u></p>
<ul>
<li>TIFF, TIF and/or PDF format only.</li>
<li>Each document must only include one member. A separate document should be uploaded for each member.</li>
<li>Name medical records using the reference # provided on the medical record request list (example # 44458135553).</li>
<li>If uploading multiple documents for a single reference #, name the individual documents as reference #_1, 2, 3, etc.</li>
<li>Documents cannot be password protected or encrypted. This is a secure site and there is no need for additional security measures.</li>
</ul>
<p><u>Upload Requirements:</u></p>
<ul>
<li>Each document cannot exceed 200MB in size</li>
<li>Do not upload more than 100 documents at a time.</li>
</ul>
<p><u>Troubleshooting Suggestions:</u></p>
<ul>
<li>Upload in batches of 20 or less if you encounter delays with large files successfully uploading.</li>
</ul>
<p>If you have any questions or need further assistance uploading documents, please contact us at <b>(866) 808-6206</b> or at
<a rel="nofollow" target="_blank" data-clickableid="clickable-29" data-clickable-id="clickable-30">UHC_QSD_Collection@uhc.com</a>.</p>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="panel">
<div class="guidePanelNode documentId_panel noSummary" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox documentId
disabledField noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___label">Submission ID</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___widget" name="documentId" value="" style=""
placeholder="-Automatically Generated-" aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox_copy___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox submitID
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox__"
style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___label">Submission ID</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___widget" name="submitID" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Section">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_320760840___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637825965714">
<div class="guideFieldNode guideTextDraw textdraw_3207608401637825712517 noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_320760840__"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_320760840__">
<p><b>Upload medical record(s)</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_558902754___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826297735">
<div class="guideFieldNode guideTextDraw textdraw_5589027541636961035880 guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_558902754__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_558902754__">
<p>Only medical records should be uploaded in this section. Each document must only include one member. A separate document should be uploaded for each member. The medical records should
document the services rendered, such as progress notes, lab results, etc.</p>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="panel">
<div class="guidePanelNode upload_medical_records_category noSummary" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachmentsHandler fdsAttachmentsHandler" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw Instructions guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw__">
<p><b>Upload Attachment (Maximum 25mb per attachment).</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachments fdsAttachmentsPanel" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachment attachmentInstance"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand/items/panel/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadSuccessInd fileUploadSuccessInd spinner noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw__">
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-4 fd-col-xs-offset-0">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox fileName
fdsFileNameText disabledField defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox___widget"
name="fileName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-5 fd-col-xs-offset-0">
<div class="guidedropdownlist guidefield">
<div class="guideFieldNode guideDropDownList attachmentCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist__"
style="">
<div class="guideFieldWidget dropDownList" style="" data-original-title="" title="">
<select
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist___widget"
name="attachmentCategory" style=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
<option value="" disabled="" selected="">Please select a category </option>
<option value="Category"> Category </option>
</select>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidebutton___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1699357186409">
<div class="guideFieldNode guideButton delete
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidebutton__"
style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidebutton___widget"
name="delete" style="" data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Remove</span>
</button>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw_1559132216___guide-item"
class="fd-col-lg-11 fd-col-lg-offset-1 fd-col-md-11 fd-col-md-offset-1 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadMessage fileUploadMessage guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__"
style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__">
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox attachmentId
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget"
name="attachmentId" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox medicalCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969__"
style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___label">Category</label>
</div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___widget"
name="medicalCategory" value="medical" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-panel-guidetextbox_1491442969___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachment">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-panel-fdsguidefileinput___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="fdsguidefileinput">
<div class="cmp-fdsguidefileinput" data-cmp-is="fdsguidefileinput">
<input type="file" accept=".pdf, .tiff,.tif" tabindex="-1" style="display: none;" aria-hidden="true" data-max-size="209715200"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand/items/panel/items/fdsguidefileinput"
max-uploads="100" multiple="">
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidebutton___guide-item"
class="fd-col-lg-5 fd-col-lg-offset-0 fd-col-md-5 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1616623289200">
<div class="guideFieldNode guideButton button1616623147439
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidebutton__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidebutton___widget" name="button1616623147439" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Upload medical records</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw_1148435580___guide-item"
class="fd-col-lg-3 fd-col-lg-offset-0 fd-col-md-3 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826737498">
<div class="guideFieldNode guideTextDraw textdraw_11484355801637823767432 noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw_1148435580__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextdraw_1148435580__">
<p>Attached:</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidenumericbox guidefield guide-1616618371695">
<div class="guideFieldNode guideNumericBox attachmentCount
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox__" style="">
<div class="guideFieldWidget numericInput" style="" data-original-title="" title="">
<input type="text" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox___widget" name="attachmentCount"
value="0" style="" placeholder="" min="" max="" step="any"
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox Extension
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571__" style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___label">Extension</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___widget"
name="Extension" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments Handler">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Medical record(s)">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1009698267___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826006668">
<div class="guideFieldNode guideTextDraw textdraw_10096982671637825797776 noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1009698267__"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1009698267__">
<p><b>Upload invoice(s)</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1899474439___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826311948">
<div class="guideFieldNode guideTextDraw textdraw_18994744391636961654858 guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1899474439__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1899474439__">
<p>Invoices to cover the cost of medical record retrieval should be separated from the medical record. If this is not possible, then upload the medical record in conjunction with the invoice in this
section. Please note: Uploading combined documents will delay the payment of the invoice. Please do not submit invoices for anything other than medical record retrieval fees.</p>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="panel">
<div class="guidePanelNode upload_invoice_category noSummary" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachmentsHandler fdsAttachmentsHandler noSummary" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/items/panel_attachmenthand"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw Instructions noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw__">
<p><b>Upload Attachment (Maximum 25mb per attachment).</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachments fdsAttachmentsPanel" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/items/panel_attachmenthand/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachment attachmentInstance noSummary"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/items/panel_attachmenthand/items/panel/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadSuccessInd fileUploadSuccessInd spinner noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw__">
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-4 fd-col-xs-offset-0">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox fileName
fdsFileNameText disabledField defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox___widget"
name="fileName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-5 fd-col-xs-offset-0">
<div class="guidedropdownlist guidefield">
<div class="guideFieldNode guideDropDownList attachmentCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist__"
style="">
<div class="guideFieldWidget dropDownList" style="" data-original-title="" title="">
<select
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist___widget"
name="attachmentCategory" style=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
<option value="" disabled="" selected="">Please select a category </option>
<option value="Category"> Category </option>
</select>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidebutton___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1699359452272">
<div class="guideFieldNode guideButton delete
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidebutton__"
style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidebutton___widget"
name="delete" style="" data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Remove</span>
</button>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw_1559132216___guide-item"
class="fd-col-lg-11 fd-col-lg-offset-1 fd-col-md-11 fd-col-md-offset-1 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadMessage fileUploadMessage noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__"
style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__">
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox attachmentId
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget"
name="attachmentId" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox invoiceCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442__"
style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___label">Category</label>
</div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget"
name="invoiceCategory" value="invoice" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachment">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-panel-fdsguidefileinput___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="fdsguidefileinput">
<div class="cmp-fdsguidefileinput" data-cmp-is="fdsguidefileinput">
<input type="file" accept=".pdf,.tiff,.tif" tabindex="-1" style="display: none;" aria-hidden="true" data-max-size="209715200"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/items/panel_attachmenthand/items/panel/items/fdsguidefileinput"
max-uploads="100" multiple="">
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidebutton___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1616623289200">
<div class="guideFieldNode guideButton button1616623147439
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidebutton__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidebutton___widget" name="button1616623147439" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Upload invoices</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw_114843___guide-item"
class="fd-col-lg-3 fd-col-lg-offset-1 fd-col-md-3 fd-col-md-offset-1 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826751131">
<div class="guideFieldNode guideTextDraw textdraw_11484355801637823767432 noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw_114843__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextdraw_114843__">
<p>Attached:</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidenumericbox guidefield guide-1616618371695">
<div class="guideFieldNode guideNumericBox attachmentCount
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox__" style="">
<div class="guideFieldWidget numericInput" style="" data-original-title="" title="">
<input type="text" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox___widget" name="attachmentCount"
value="0" style="" placeholder="" min="" max="" step="any"
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox Extension
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571__" style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___label">Extension</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___widget"
name="Extension" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments Handler">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Invoice(s)">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1509091288___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826013746">
<div class="guideFieldNode guideTextDraw textdraw_15090912881637825832417 noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1509091288__"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1509091288__">
<p><b>Chart not available document(s)</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_444319792___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826320182">
<div class="guideFieldNode guideTextDraw textdraw_4443197921636961706757 guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_444319792__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_444319792__">
<p>If you receive a request for a member(s) who was not your patient or no services were rendered during the requested timeframe, please upload the medical record list with the appropriate box
checked to state the reason the information requested is not available.</p>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="panel">
<div class="guidePanelNode no_category_attachments noSummary" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_662168662" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachmentsHandler fdsAttachmentsHandler" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_662168662/items/panel_attachmenthand"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw Instructions noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw__">
<p><b>Upload Attachment (Maximum 25mb per attachment).</b></p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachments fdsAttachmentsPanel" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_662168662/items/panel_attachmenthand/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode attachment attachmentInstance"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_662168662/items/panel_attachmenthand/items/panel/items/panel"
style=";" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel___guide-item-container"
class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadSuccessInd fileUploadSuccessInd spinner noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw__">
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-4 fd-col-xs-offset-0">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox fileName
fdsFileNameText disabledField defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox___widget"
name="fileName" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-5 fd-col-xs-offset-0">
<div class="guidedropdownlist guidefield">
<div class="guideFieldNode guideDropDownList attachmentCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist__"
style="">
<div class="guideFieldWidget dropDownList" style="" data-original-title="" title="">
<select
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist___widget"
name="attachmentCategory" style=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
<option value="" disabled="" selected="">Please select a category </option>
<option value="Category"> Category </option>
</select>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidedropdownlist___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidebutton___guide-item"
class="fd-col-lg-1 fd-col-lg-offset-0 fd-col-md-1 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-1 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1699363353830">
<div class="guideFieldNode guideButton delete
defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidebutton__"
style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidebutton___widget"
name="delete" style="" data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Remove</span>
</button>
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw_1559132216___guide-item"
class="fd-col-lg-11 fd-col-lg-offset-1 fd-col-md-11 fd-col-md-offset-1 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield">
<div class="guideFieldNode guideTextDraw fileUploadMessage fileUploadMessage guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__"
style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextdraw_1559132216__">
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox attachmentId
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587__"
style="">
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget"
name="attachmentId" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1691307587___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox noCategory
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442__"
style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___label">Category</label>
</div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget"
name="noCategory" value="other" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget_desc">
</div>
<div class="guideFieldError"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-panel-guidetextbox_1491442___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachment">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-panel-fdsguidefileinput___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="fdsguidefileinput">
<div class="cmp-fdsguidefileinput" data-cmp-is="fdsguidefileinput">
<input type="file" accept=".pdf,.tiff,.tif" tabindex="-1" style="display: none;" aria-hidden="true" data-max-size="209715200"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_662168662/items/panel_attachmenthand/items/panel/items/fdsguidefileinput"
max-uploads="100" multiple="">
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidebutton___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidebutton guidefield guide-1616623289200">
<div class="guideFieldNode guideButton button1616623147439
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidebutton__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidebutton__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium Button" type="button"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidebutton___widget" name="button1616623147439" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Upload other</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidebutton___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw_114843___guide-item"
class="fd-col-lg-3 fd-col-lg-offset-1 fd-col-md-3 fd-col-md-offset-1 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637826758877">
<div class="guideFieldNode guideTextDraw textdraw_11484355801637823767432 noSummary guideStaticText"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw_114843__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextdraw_114843__">
<p>Attached:</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox___guide-item"
class="fd-col-lg-4 fd-col-lg-offset-0 fd-col-md-4 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidenumericbox guidefield guide-1616618371695">
<div class="guideFieldNode guideNumericBox attachmentCount
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox__" style="">
<div class="guideFieldWidget numericInput" style="" data-original-title="" title="">
<input type="text" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox___widget" name="attachmentCount"
value="0" style="" placeholder="" min="" max="" step="any"
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___guide-item"
class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextbox guidefield">
<div class="guideFieldNode guideTextBox Extension
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571__"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571__" style="">
<div class="guideFieldLabel top" style=""><label
for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___label">Extension</label></div>
<div class="guideFieldWidget textField " style="" data-original-title="" title="">
<input type="text" autocomplete="off" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___widget"
name="Extension" value="" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_662168662-panel_attachmenthand-guidetextbox_4820571___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments Handler">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Chart not available document(s)">
</div>
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextalert guidetextbox guidefield guide-1700559517323">
<div class="guideFieldNode guideTextBox Noattachmentalert
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert__" style="">
<link rel="stylesheet" href="/etc.clientlibs/dfa-optum/fd/af/components/guidetextalert/v2/guidetextalert/clientlibs.min.css" type="text/css">
<div class="guideFieldWidget textField multiline dfatextalert-v2" style="" data-original-title="" title="">
<textarea id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert___widget" autocomplete="name" name="Noattachmentalert" style="" placeholder=""
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert___widget_desc"></textarea>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextalert___widget_desc">
</div>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637128864679">
<div class="guideFieldNode guideTextDraw errorMessageText noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954__">
<p>Error: Please upload at least one document</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1008777430___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield guide-1638778379606">
<div class="guideFieldNode guideTextDraw errorFormat noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1008777430__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1008777430__">
<p>Invalid file formats attached - please remove</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954256___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637128864679">
<div class="guideFieldNode guideTextDraw errorMessage noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954256__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954256__">
<p>Error: A duplicate document has been uploaded. Please remove the duplicate document.</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___guide-item"
class="fd-col-lg-9 fd-col-lg-offset-0 fd-col-md-9 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidenumericbox guidefield">
<div class="guideFieldNode guideNumericBox totalDocumentsAttached
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox__" style="">
<div class="guideFieldLabel top" style=""><label for="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___widget"
id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___label">Total Documents Attached</label></div>
<div class="guideFieldWidget numericInput" style="" data-original-title="" title="">
<input type="text" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___widget" name="totalDocumentsAttached" value="" style="" placeholder="" min="" max=""
step="any" aria-describedby="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___widget_desc">
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox___widget_desc">
</div>
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<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676___guide-item"
class="fd-col-lg-2 fd-col-lg-offset-0 fd-lg-newline fd-col-md-2 fd-col-md-offset-0 fd-md-newline fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="previtemnav guidebutton guidefield guide-1624479879878">
<div class="guideFieldNode guideButton previtemnav1624472473315
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676__"
style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium movePrev" type="button" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676___widget" name="previtemnav1624472473315"
style="" data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Back</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676___widget_desc">
</div>
</div>
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</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav___guide-item"
class="fd-col-lg-2 fd-col-lg-offset-0 fd-col-md-2 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="nextitemnav guidebutton guidefield guide-1631131041168">
<div class="guideFieldNode guideButton nextitemnav1631129939308
noSummary defaultFieldLayout" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav__" data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav__" style="">
<div class="guideFieldWidget guideFieldButtonWidget" style="" data-original-title="" title="">
<button class="button-default button-medium moveNext" type="button" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav___widget" name="nextitemnav1631129939308" style=""
data-original-title="" title="">
<span class="iconButton-icon"></span>
<span class="iconButton-label" data-guide-button-label="true" style="">Next</span>
</button>
</div>
<div class="guideFieldError" id="guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav___widget_desc">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachment details">
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</div>
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<div id="im_guideContainer-rootPanel-panel1617372512792-panel__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel___guide-item" role="tabpanel" aria-labelledby="guideContainer-rootPanel-panel1617372512792-panel___guide-item-nav"
data-guide-parent-id="guideContainer-rootPanel-panel1617372512792__">
<div class="panel">
<div class="guidePanelNode verify_Submit noSummary" id="guideContainer-rootPanel-panel1617372512792-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
<div id="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetextdraw guidefield guide-1637942243429">
<div class="guideFieldNode guideTextDraw Heading noSummary guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw__">
<h2 style="font-size: 26.0px;"><b>Review and submit</b></h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw_602855052___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="guidetextdraw guidefield guide-1697015456703">
<div class="guideFieldNode guideTextDraw verifyInstructions guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw_602855052__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw_602855052__">
<p>Fields marked with an asterisk * are required</p>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel-summarytemplate___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="summarytemplate guidetextdraw guidefield guide-1631207951522">
<div class="guideFieldNode guideTextDraw summarytemplate1631131568499 guideStaticText" id="guideContainer-rootPanel-panel1617372512792-panel-summarytemplate__" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel-summarytemplate__">
<p><b>Review the details below and make any changes before submitting your request</b></p>
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{{if title.includes("Enter email address (name@domain.com) *")}}
<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Enter email address *</td>
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<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Group name *</td>
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<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Contact first name *</td>
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<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Contact last name *</td>
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<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Phone number *</td>
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{{if title.includes('Comments')}}
<td style="vertical-align: top; word-wrap: break-word;color:#000000;">Comments</td>
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{{if title.includes('File name')}}
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{{else }}
<td style="vertical-align: top; word-wrap: break-word; color:#000000;">{{:title}}</td>
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{{if value}}
<td style="width: 60%; vertical-align: top; display:table-cell; word-wrap:break-word; font-family: UHC2020 Sans, Arial, Helvetica, sans-serif; padding: 5px; padding-left: 100px; color: #000000;">
{{:formattedValue}} </td>
{{else}}
<td style="vertical-align: top; display:table-cell; word-wrap:break-word; font-family: UHC2020 Sans, Arial, Helvetica, sans-serif; padding: 5px; padding-left: 100px; color: #000000;"> </td>
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{{/if}}
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{{/for}}
</table>
</script>
<div id="summarytemplate1631131568499_summary-view">
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<script type="text/javascript">
$(document).ready(function() {
window.optum.dfa.summary.registerNav('summarytemplate1631131568499');
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<div id="im_guideContainer-rootPanel-panel1617372512792-panel-panel__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel-panel___guide-item"
class="fd-col-lg-12 fd-col-lg-offset-0 fd-col-md-12 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="panel">
<div class="guidePanelNode panel1631122991070 noSummary" id="guideContainer-rootPanel-panel1617372512792-panel-panel__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/items/panel" style=";"
data-guide-view-bind="guideContainer-rootPanel-panel1617372512792-panel-panel__">
<div class="gridFluidLayout2 gridFluidLayout">
<div id="guideContainer-rootPanel-panel1617372512792-panel-panel___guide-item-container" class="guideLayout guideGridFluidLayout">
<div class="fd-row guideGridFluidLayout2Container">
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<div class="section afEditorPlaceholder cq-placeholder" data-emptytext="Drag components here - Attachments">
</div>
</div>
</div>
</div>
</div>
<div id="im_guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955__" style="display: none" data-guide-template-marker="true"></div>
<div id="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955___guide-item" class="fd-col-lg-12 fd-col-md-12 fd-col-sm-12 fd-col-xs-12">
<div class="panel">
<div class="guidePanelNode panel_17763649551700139525325 " id="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955__"
data-path="/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/items/panel_1776364955" style=";"
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<div class="gridFluidLayout2 gridFluidLayout">
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<h2 style="font-size: 18.0px;"><b>Agree and sign</b></h2>
</div>
</div>
</div>
<div id="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955-guidetermsandconditi___guide-item"
class="fd-col-lg-23 fd-col-lg-offset-0 fd-col-md-23 fd-col-md-offset-0 fd-col-sm-12 fd-col-sm-offset-0 fd-col-xs-12 fd-col-xs-offset-0">
<div class="guidetermsandconditions guidefield guide-1637049908645">
<div class="guideFieldNode guideTermsAndConditions termsandconditions
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conditions</label></div>
<div class="guideFieldWidget afTermsAndConditions" style="" data-original-title="" title="">
<div tabindex="0" class="afTncContentArea">
<div class="guide-sr-only guide-tnc-sr-only"></div>
<div class="guide-tnc-content" style="">
<p>From time to time, United Healthcare Services, Inc., or their affiliates, subsidiaries, agents, contractors, or vendors (we or us) may be required by law to provide to you certain
written notices or disclosures. Please read the information below carefully and agree to this Electronic Record nd Signature Disclosure (ERSD). Please confirm your agreement by
selecting the check-box next to ‘I agree to use electronic records and signatures’ before signing this document.<br>
</p>
<p><b>Getting paper copies</b></p>
<p>At any time, you may request a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to
you during and immediately after this signing session.</p>
<p><b>Acknowledging your access and consent to receive and sign documents electronically</b></p>
<p>By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm that:<br> • You intend to sign the document electronically.<br> • You can access
and read this Electronic Record and Signature Disclosure.<br> • You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and
Disclosure to a location where you can print it, for future reference and access.<br> • You acknowledge that emails containing your protected health information will be sent
unencrypted and there is a risk of interception or disclosure of the contents of the emails. </p>
<p>By selecting Adopt and Sign, I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I (or my agent) use
them on documents, including legally binding contracts - just the same as a pen-and-paper signature or initial</p>
<p>By signing below, I am stating that the information above is correct. Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete
or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.</p>
</div>
</div>
<div class="guide-tnc-checkbox guide-tnc-checkbox-disabled">
<div class="guide-tnc-checkboxwidget left">
<input type="checkbox" disabled="disabled" id="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955-guidetermsandconditi___tncCheckBox"
aria-describedby="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955-guidetermsandconditi___widget_desc"
aria-label="By checking this box and signing below, I acknowledge that I have read, understand and agree to all of the above.*">
</div>
<div class="guideWidgetLabel right">
<label for="guideContainer-rootPanel-panel1617372512792-panel-panel_1776364955-guidetermsandconditi___tncCheckBox"> By checking this box and signing below, I acknowledge that I have
read, understand and agree to all of the above.* </label>
</div>
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"guidejson": "{\"templateId\":\"guideContainer__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer\",\"guideNodeClass\":\"guideContainerNode\",\"thankYouOption\":\"message\",\"disableSwipeGesture\":false,\"enableAsyncSubmission\":\"true\",\"clientLibRef\":\"dfa-optum.forms\",\"thankYouMessage\":\"Thank you for submitting the form.\",\"guideCss\":\"guideContainer\",\"useExistingAF\":\"false\",\"enableLayoutLayer\":\"false\",\"autoSaveStrategyType\":\"fd/fp/components/actions/autosave/timebased\",\"fd:version\":\"1.1\",\"dorTemplateRef\":\"/content/dam/formsanddocuments/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/renditions/dorTemplate\",\"schemaType\":\"formdatamodel\",\"schemaRef\":\"/content/dam/formsanddocuments-fdm/uhc/sharedservices/dfa/dfa-fields\",\"name\":\"guide1\",\"fieldParameterMapping\":[\"formUID=formUniqueId\",\"documentId=documentId\",\"FormName=formName\",\"fdmPath=fdmPath\"],\"themeRef\":\"/content/dam/formsanddocuments-themes/uhc/sharedservices/dfa/optum\",\"sling:resourceType\":\"fd/af/components/guideContainer\",\"textIsRich\":\"true\",\"dorType\":\"generate\",\"actionType\":\"dfa-optum/submit/azurefdssubmit\",\"submitError\":\"\\ntry {\\n eval(\\\"if(remainingAttempts.value > 0){ \\\\nwindow.optum.dfa.handleError(\\\\\\\"We experienced a problem and can\\u2019t confirm the status of your submission here. 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For help, please call the service number on the back of your member ID card or message us for assistance.\\\\\\\");\\\\n window.optum.dfa.elementButtonClickedDone(postForm.somExpression);\\\\n}\\\\n\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\",\"submitSuccess\":\"\\ntry {\\n eval(\\\"window.optum.dfa.prefetchDorData();\\\\nwindow.optum.dfa.showModal(thankYouPagepanelMed.name);\\\\nwizardPanel.enabled= false;\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\",\"layout\":{\"templateId\":\"guideContainer-layout__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/layout\",\"toolbarPosition\":\"Bottom\",\"sling:resourceType\":\"fd/af/layouts/defaultGuideLayout\",\"mobileLayout\":\"dfa-optum/fd/af/layouts/mobile/step\"},\"rootPanel\":{\"templateId\":\"guideContainer-rootPanel__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel\",\"guideNodeClass\":\"rootPanelNode\",\"jcr:title\":\"Root Panel\",\"validateOnStepCompletion\":false,\"panelSetType\":\"Navigable\",\"dorExcludeTitle\":\"true\",\"name\":\"guideRootPanel\",\"sling:resourceType\":\"fd/af/components/rootPanel\",\"dorExcludeDescription\":\"true\",\"editable\":true,\"completionExpReq\":false,\"initScript\":\"\\ntry {\\n eval(\\\"window.optum.dfa.addErrorHandler(function(message){\\\\n\\tserviceError.errorMessage.value = \\\\\\\"<p>\\\\\\\" + message + \\\\\\\"<\\/p>\\\\\\\";\\\\n \\twindow.optum.dfa.showModal(serviceError.name);\\\\n});\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\ntry {\\n eval(\\\"window.optum.dfa.qualtrics.formName = FormName.value;\\\\nwindow.optum.dfa.qualtrics.formUid = formUID.value;\\\\nwindow.optum.dfa.qualtrics.formLocation = \\\\\\\"guide[0].guide1[0].guideRootPanel[0]\\\\\\\";\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\",\"nonLocalizedTitle\":\"Root Panel\",\"layout\":{\"templateId\":\"guideContainer-rootPanel-layout__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/layout\",\"toolbarPosition\":\"Bottom\",\"sling:resourceType\":\"fd/af/layouts/gridFluidLayout2\",\"nonNavigable\":true},\"items\":{\"panel\":{\"templateId\":\"guideContainer-rootPanel-panel__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel\",\"guideNodeClass\":\"guidePanel\",\"jcr:title\":\"Form Instructions\",\"validateOnStepCompletion\":false,\"name\":\"formInstructions\",\"sling:resourceType\":\"fd/af/components/panel\",\"textIsRich\":\"true\",\"nonLocalizedTitle\":\"Form Instructions\",\"layout\":{\"templateId\":\"guideContainer-rootPanel-panel-layout__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/layout\",\"dorNumCols\":\"1\",\"toolbarPosition\":\"Bottom\",\"columns\":\"1\",\"sling:resourceType\":\"fd/af/layouts/gridFluidLayout2\",\"dorLayoutType\":\"columnar\",\"nonNavigable\":true},\"items\":{\"guidetextdraw\":{\"templateId\":\"guideContainer-rootPanel-panel-guidetextdraw__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/guidetextdraw\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>For health care professionals of Quality Program File Submissions<\\/p>\\n\",\"name\":\"textdraw1615450538843\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"panel1615449839911\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911\",\"guideNodeClass\":\"guidePanel\",\"jcr:title\":\"LeftPanel\",\"validateOnStepCompletion\":false,\"css\":\"noSummary\",\"name\":\"LeftPanel\",\"sling:resourceType\":\"fd/af/components/panel\",\"textIsRich\":\"true\",\"nonLocalizedTitle\":\"LeftPanel\",\"items\":{\"guidetextdraw_720575\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guidetextdraw_720575__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guidetextdraw_720575\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<h2 style=\\\"font-size: 13.0pt;\\\"><b>Estimated time to complete:<\\/b><\\/h2>\\n\",\"name\":\"estimatedtimetto\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guideimage\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guideimage__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guideimage\",\"guideNodeClass\":\"guideImage\",\"jcr:title\":\"clock\",\"fileReference\":\"/content/dam/dfa-optum/Clock.png\",\"altText\":\" \",\"fileName\":\"Clock.png\",\"name\":\"clock\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guideimage\",\"nonLocalizedTitle\":\"clock\",\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guideimage-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guideimage/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guideimage-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guideimage/cq:responsive/default\",\"offset\":\"0\",\"width\":\"3\",\"behavior\":\"newline\"}},\"style\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guideimage-style__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guideimage/style\",\"af_guideimage\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guideimage-style-af_guideimage__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guideimage/style/af_guideimage\",\"default#default\":[\"width:48px\",\"height:48px\"]}}},\"guidetextdraw_932492979\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guidetextdraw_932492979__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guidetextdraw_932492979\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p><b>5 - 10 minutes<\\/b><\\/p>\\n\",\"name\":\"textdraw_9324929791625849503499\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-guidetextdraw__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/items/guidetextdraw\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<ul>\\n<li>This form is for health care professionals who are submitting medical records to fulfill HEDIS ® and quality program requests<\\/li>\\n<\\/ul>\\n\",\"name\":\"textdraw1625848751461\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]}},\"layout\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-layout__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/layout\",\"toolbarPosition\":\"Bottom\",\"columns\":\"1\",\"sling:resourceType\":\"fd/af/layouts/gridFluidLayout2\",\"nonNavigable\":true},\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449839911-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449839911/cq:responsive/default\",\"offset\":\"0\",\"width\":\"4\"}}},\"panel1615449873898\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898\",\"guideNodeClass\":\"guidePanel\",\"jcr:title\":\"RightPanel\",\"validateOnStepCompletion\":false,\"css\":\"noSummary\",\"name\":\"RightPanel\",\"sling:resourceType\":\"fd/af/components/panel\",\"textIsRich\":\"true\",\"nonLocalizedTitle\":\"RightPanel\",\"items\":{\"guidetextdraw_1388115056\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_1388115056__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898/items/guidetextdraw_1388115056\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<h2 style=\\\"font-size: 13.0pt;\\\"><b>What do I need?<\\/b><\\/h2>\\n\",\"name\":\"textdraw_13881150561625849107264\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_205188_1513943985\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_205188_1513943985__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898/items/guidetextdraw_205188_1513943985\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>To complete this submission, you may be required to provide some or all of the information:<\\/p>\\n<ul>\\n<li>Group name<\\/li>\\n<li>Contact first and last name<\\/li>\\n<li>Return phone number in case there are questions or issues with the submission<\\/li>\\n<li>Reference # provided on the medical record request list<\\/li>\\n<\\/ul>\\n\",\"name\":\"whatdoineed\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_685866706\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_685866706__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898/items/guidetextdraw_685866706\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<h2 style=\\\"font-size: 13.0pt;\\\"><b>Important things to know before completing the form<\\/b><\\/h2>\\n\",\"name\":\"textdraw_6858667061625849147168\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_2078509262\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_2078509262__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898/items/guidetextdraw_2078509262\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<ul>\\n<li>Name medical records using the reference # on the medical record request list (example reference # 44458135553)<\\/li>\\n<li>Files must be in either PDF, TIFF, or TIF format only. No other formats are accepted. The system will give you a real-time notification if the format of the uploaded document(s) is unacceptable.<\\/li>\\n<li>Do not submit password protected documents. 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No other formats are accepted. (The system will give you a real-time notification if the format of the uploaded document(s) is unacceptable.)<\\/li>\\n<li>Do not submit password protected documents. This is a secure site and there is no need for additional security measures.<\\/li>\\n<\\/ul>\\n\",\"textIsRich\":\"true\"},\"guidetextdraw_1437265735\":{\"templateId\":\"guideContainer-rootPanel-panel-panel1615449873898-guidetextdraw_1437265735__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel/items/panel1615449873898/items/guidetextdraw_1437265735\",\"text\":\"<ul>\\n<li>Name medical records using the Reference # provided on the medical record request list (example reference #: 44458135553)<\\/li>\\n<li>File must be either PDF or TIFF format only. No other formats are accepted. 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this.visible;\\n}\\n else {\\n Visibility;\\n}\",\"nonLocalizedTitle\":\"ValidationPanel\",\"items\":{\"guidetextbox_9722937\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel1636721920885-panel1635922949691-guidetextbox_9722937__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel1636721920885/items/panel1635922949691/items/guidetextbox_9722937\",\"guideNodeClass\":\"guideTextBox\",\"jcr:title\":\"Enter code *\",\"validatePictureClauseMessage\":\"Error: Enter the code provided in the email\",\"displayPictureClause\":\"^\\\\d{6}$\",\"length\":\"6\",\"displayPatternType\":\"custom\",\"mandatory\":\"true\",\"name\":\"Code\",\"displayIsSameAsValidate\":\"true\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextbox\",\"autofillFieldKeyword\":\"name\",\"mandatoryMessage\":\"Error: Enter 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this.parent.instanceManager.instances[this.parent.index].somExpression);\\\\nif(attachmentInstanceCount > 1){\\\\n this.parent.instanceManager.removeInstance(this.parent.index);\\\\n upload_medical_records_category.attachmentsHandler.attachmentCount.value = this.parent.instanceManager.instanceCount;\\\\n} else{\\\\n this.parent.instanceManager.instances[this.parent.index].resetData();\\\\n //this.parent.instanceManager.instances[this.parent.index].items[1].css = \\\\\\\"fdsFileNameText disabledField\\\\\\\";\\\\n //console.log(\\\\\\\"asdfasdf\\\\\\\" + this.parent.instanceManager.instances[this.parent.index].items[1].css);\\\\n this.parent.instanceManager.instances[this.parent.index].visible = false;\\\\n // this.parent.instanceManager.instances[this.parent.index].items.filename.visible = false;\\\\n //console.log(this.parent.instanceManager.instances[this.parent.index].items.filename);\\\\n //console.log(\\\\\\\"resetting the first instance \\\\\\\" + 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wrap;\"],\"default#default\":[\"cssOverride:display:flex;\\n\"],\"default#success\":[\"cssOverride:border: none;\"]},\"af_textbox\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox-style-af_textbox__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand/items/guidetextbox/style/af_textbox\",\"default#default\":[\"margin-top:8px\"],\"default#default#ui\":[\"marginLock:linkOff\",\"marginPopover:8px, \\u2014, \\u2014, \\u2014\"]}}},\"guidetextbox_4820571\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-panel_attachmenthand-guidetextbox_4820571__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/items/panel_attachmenthand/items/guidetextbox_4820571\",\"guideNodeClass\":\"guideTextBox\",\"jcr:title\":\"Extension\",\"css\":\"noSummary\",\"name\":\"Extension\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextbox\",\"autofillFieldKeyword\":\"name\",\"textIsRich\":[\"true\",\"true\",\"true\"],\"nonLocalizedTitle\":\"Extension\"}}}},\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1349973283-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1349973283/cq:responsive/default\",\"offset\":\"0\",\"width\":\"9\"}}},\"guidetextdraw_1009698267\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1009698267__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidetextdraw_1009698267\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p><b>Upload invoice(s)<\\/b><\\/p>\\n\",\"css\":\"noSummary \",\"name\":\"textdraw_10096982671637825797776\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_1899474439\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1899474439__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidetextdraw_1899474439\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>Invoices to cover the cost of medical record retrieval should be separated from the medical record. 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Please do not submit invoices for anything other than medical record retrieval 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\\u2014\"]}}},\"guidetextbox_4820571\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-panel_attachmenthand-guidetextbox_4820571__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/items/panel_attachmenthand/items/guidetextbox_4820571\",\"guideNodeClass\":\"guideTextBox\",\"jcr:title\":\"Extension\",\"css\":\"noSummary\",\"name\":\"Extension\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextbox\",\"autofillFieldKeyword\":\"name\",\"textIsRich\":[\"true\",\"true\",\"true\"],\"nonLocalizedTitle\":\"Extension\"}}}},\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-panel_1929317442-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/panel_1929317442/cq:responsive/default\",\"offset\":\"0\",\"width\":\"9\"}}},\"guidetextdraw_1509091288\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1509091288__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidetextdraw_1509091288\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p><b>Chart 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{\\n eval(\\\"errorMessage.visible=false;\\\\nerrorFormat.visible=false;\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\ntry {\\n eval(\\\"var attachmentPanel = guideBridge.resolveNode(this.parent.instanceManager.instances[this.parent.index].somExpression);\\\\n//var attachmentPanel = guideBridge.resolveNode(upload_medical_records_category.attachmentsHandler.attachments.attachment.somExpression);\\\\nvar path = window.optum.dfa.fdsfileupload.getHandlerObjects(no_category_attachments.attachmentsHandler.somExpression).fdsGuideInput.getAttribute(\\\\\\\"data-path\\\\\\\");\\\\n\\\\n var payload = {\\\\n \\\\\\\"documentId\\\\\\\": window.optum.dfa.fdsfileupload.documentId,\\\\n \\\\\\\"attachmentId\\\\\\\": attachmentPanel.attachmentId.value\\\\n };\\\\n\\\\n//console.log(\\\\\\\"AttachmentPanel\\\\\\\" + attachmentPanel);\\\\n//console.log(\\\\\\\"path: \\\\\\\" + path);\\\\n//console.log(\\\\\\\"documentId\\\\\\\" + payload.documentId);\\\\n//console.log(\\\\\\\"attachmentId\\\\\\\" + payload.attachmentId);\\\\n \\\\n $.ajax({\\\\n method: \\\\\\\"POST\\\\\\\", \\\\n url: path + \\\\\\\".delete.json\\\\\\\",\\\\n data: JSON.stringify(payload),\\\\n contentType: 'application/json',\\\\n success: function (response, textStatus, jqXHR) {\\\\n JSON.parse(response);\\\\n //Remove/reset panel from the form\\\\n //window.optum.dfa.fdsfileupload.handlePanelDelete(attachmentPanel);\\\\n //window.optum.dfa.fdsfileupload.fdm.reduceCount(attachmentPanel);\\\\n \\t//console.log(response);\\\\n }\\\\n \\t\\t});\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\ntry {\\n eval(\\\"var attachmentInstanceCount = this.parent.instanceManager.instanceCount;\\\\n//console.log(\\\\\\\"current instance somExpression\\\\\\\" + this.parent.instanceManager.instances[this.parent.index].somExpression);\\\\nif(attachmentInstanceCount > 1){\\\\n this.parent.instanceManager.removeInstance(this.parent.index);\\\\n no_category_attachments.attachmentsHandler.attachmentCount.value = this.parent.instanceManager.instanceCount;\\\\n} else{\\\\n this.parent.instanceManager.instances[this.parent.index].resetData();\\\\n //this.parent.instanceManager.instances[this.parent.index].items[1].css = \\\\\\\"fdsFileNameText disabledField\\\\\\\";\\\\n //console.log(\\\\\\\"asdfasdf\\\\\\\" + this.parent.instanceManager.instances[this.parent.index].items[1].css);\\\\n this.parent.instanceManager.instances[this.parent.index].visible = false;\\\\n // this.parent.instanceManager.instances[this.parent.index].items.filename.visible = false;\\\\n //console.log(this.parent.instanceManager.instances[this.parent.index].items.filename);\\\\n //console.log(\\\\\\\"resetting the first instance \\\\\\\" + this.parent.instanceManager.instances[this.parent.index].resetData());\\\\n no_category_attachments.attachmentsHandler.attachmentCount.value = this.parent.instanceManager.instanceCount - 1;\\\\n}\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + 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Please upload at least one document<\\/p>\\n\",\"css\":\"noSummary\",\"name\":\"errorMessageText\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_1008777430\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_1008777430__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidetextdraw_1008777430\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>Invalid file formats attached - please remove<\\/p>\\n\",\"css\":\"noSummary\",\"name\":\"errorFormat\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_461954256\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidetextdraw_461954256__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidetextdraw_461954256\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>Error: A duplicate document has been uploaded. Please remove the duplicate document.<\\/p>\\n\",\"css\":\"noSummary\",\"name\":\"errorMessage\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidenumericbox\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidenumericbox\",\"guideNodeClass\":\"guideNumericBox\",\"jcr:title\":\"Total Documents Attached\",\"enabled\":false,\"css\":\"noSummary\",\"name\":\"totalDocumentsAttached\",\"visible\":false,\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/guidenumericbox\",\"textIsRich\":[\"true\",\"true\"],\"calcExp\":\"var Calculate;\\n\\ntry {\\n Calculate = guidelib.util.GuideUtil._addValues(guidelib.util.GuideUtil._addValues(upload_medical_records_category.attachmentsHandler.attachmentCount.value, upload_invoice_category.attachmentsHandler.attachmentCount.value ) , no_category_attachments.attachmentsHandler.attachmentCount.value ) ;\\n \\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\nif (Calculate === undefined) {\\n this.value;\\n}\\n else {\\n Calculate;\\n}\",\"nonLocalizedTitle\":\"Total Documents Attached\",\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidenumericbox/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-guidenumericbox-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/guidenumericbox/cq:responsive/default\",\"offset\":\"0\",\"width\":\"9\"}}},\"previtemnav_12205676\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/previtemnav_12205676\",\"guideNodeClass\":\"guideButton\",\"jcr:title\":\"Back\",\"fd:targetVersion\":\"1.1\",\"css\":\"noSummary\",\"name\":\"previtemnav1624472473315\",\"type\":\"movePrev\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/actions/previtemnav\",\"textIsRich\":[\"true\",\"true\"],\"clickExp\":\"\\ntry {\\n eval(\\\"guideBridge.setFocus(wizardPanel.somExpression, \\\\\\\"prevItem\\\\\\\",true);\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\",\"nonLocalizedTitle\":\"Back\",\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/previtemnav_12205676/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/previtemnav_12205676/cq:responsive/default\",\"offset\":\"0\",\"width\":\"2\",\"behavior\":\"newline\"}},\"style\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676-style__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/previtemnav_12205676/style\",\"af_previtemnavbutton\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-previtemnav_12205676-style-af_previtemnavbutton__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/previtemnav_12205676/style/af_previtemnavbutton\",\"default#default\":[\"margin-left:8px\",\"margin-top:24px\"],\"default#default#ui\":[\"marginLock:linkOff\",\"marginPopover:24px, \\u2014, \\u2014, 8px\"]}}},\"nextitemnav\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/nextitemnav\",\"guideNodeClass\":\"guideButton\",\"jcr:title\":\"Next\",\"fd:targetVersion\":\"1.1\",\"css\":\"noSummary\",\"name\":\"nextitemnav1631129939308\",\"type\":\"moveNext\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/actions/nextitemnav\",\"textIsRich\":[\"true\",\"true\"],\"clickExp\":\"\\ntry {\\n eval(\\\"// latest\\\\n\\\\n//original with undefined\\\\nif(qestion.validate()){\\\\nvar nextVal=true;\\\\nvar nextValInv=true;\\\\nvar nextValNa=true;\\\\nvar arr;\\\\nvar arrInv;\\\\nvar arrNa;\\\\nvar hashmap = new Map();\\\\n\\\\nvar formatCheck=true;\\\\nvar filemap = new Map();\\\\nvar fileformat;\\\\n\\\\nguideBridge.getData({\\\\nsuccess: function(guideResultObject){\\\\nvar jsonVar = guideResultObject.data;\\\\nvar jsonObj = JSON.parse(jsonVar);\\\\n arr=jsonObj.afData.afBoundData.data.attachments.medicalRecords;\\\\narrInv=jsonObj.afData.afBoundData.data.attachments.invoice;\\\\narrNa=jsonObj.afData.afBoundData.data.attachments.noCategory;\\\\n}\\\\n});\\\\n\\\\nconsole.log(\\\\\\\"arr length\\\\\\\"+arr.length);\\\\n\\\\nfor(var i=0;i<arr.length;i++){\\\\nif(hashmap.has(arr[i].name)===false && typeof(arr[i].name)!=='undefined'){\\\\n console.log(\\\\\\\"inside if\\\\\\\");\\\\nhashmap.set(arr[i].name,arr[i].name);\\\\nerrorMessage.visible=false;\\\\nnextVal=true;\\\\n}\\\\nelse{\\\\n if(arr[i].name!==undefined){\\\\n console.log(\\\\\\\"arr[i] not undefined, duplicate\\\\\\\");\\\\nerrorMessage.visible=true;\\\\n//errorMessageMedical.visible = true;\\\\nnextVal=false;\\\\nbreak;}\\\\n else{\\\\n console.log(\\\\\\\"arr[i] undefined, empty\\\\\\\");\\\\n nextVal=true;\\\\n errorMessage.visible=false;\\\\n break;\\\\n }\\\\n}\\\\n}\\\\n\\\\nconsole.log(\\\\\\\"after 1st loop nextVa\\\\\\\");\\\\nconsole.log(nextVal);\\\\nconsole.log(nextValInv);\\\\nconsole.log(nextValNa);\\\\nconsole.log(hashmap);\\\\n\\\\nconsole.log(\\\\\\\"arrInv length\\\\\\\"+arr.length);\\\\n\\\\nfor(var i=0;i<arrInv.length;i++){\\\\n\\\\nif(hashmap.has(arrInv[i].name)===false && arrInv[i].name!==undefined){\\\\nhashmap.set(arrInv[i].name,arrInv[i].name);\\\\n if(nextVal===false){\\\\n errorMessage.visible=true;\\\\n }\\\\n else{\\\\n errorMessage.visible=false;}\\\\nnextValInv=true;\\\\n}\\\\nelse{\\\\n if(arrInv[i].name!==undefined){\\\\n console.log(\\\\\\\"arrInv[i] not undefined, duplicate\\\\\\\");\\\\n errorMessage.visible=true;\\\\nnextValInv=false;\\\\nbreak;}\\\\n else{\\\\n console.log(\\\\\\\"arrInv[i] undefined, empty\\\\\\\");\\\\n nextValInv=true;\\\\n if(nextVal===false){\\\\n errorMessage.visible=true;\\\\n }\\\\n else{\\\\n errorMessage.visible=false;}\\\\n //errorMessage.visible=false;\\\\n break;\\\\n }\\\\n}\\\\n}\\\\n\\\\nconsole.log(\\\\\\\"after 2nd loop\\\\\\\");\\\\nconsole.log(nextVal);\\\\nconsole.log(nextValInv);\\\\nconsole.log(nextValNa);\\\\nconsole.log(hashmap);\\\\n\\\\n\\\\nfor(var i=0;i<arrNa.length;i++){\\\\nif(hashmap.has(arrNa[i].name)===false && arrNa[i].name!==undefined){\\\\n console.log(\\\\\\\"maparrNa[i].name===false\\\\\\\");\\\\nhashmap.set(arrNa[i].name,arrNa[i].name);\\\\n if(nextVal===false || nextValInv===false){\\\\n errorMessage.visible=true;\\\\n }else{\\\\nerrorMessage.visible=false;}\\\\nnextValNa=true;\\\\n}\\\\nelse{\\\\n if(arrNa[i].name!==undefined){\\\\n console.log(\\\\\\\"arrNa[i].name!==undefined\\\\\\\");\\\\nerrorMessage.visible=true;\\\\nnextValNa=false;\\\\nbreak;}\\\\n else{\\\\n nextValNa=true;\\\\n console.log(\\\\\\\"erroMsg.visible=false\\\\\\\");\\\\n if(nextVal===false || nextValInv===false){\\\\n errorMessage.visible=true;\\\\n }\\\\n else{\\\\n errorMessage.visible=false;}\\\\n break;\\\\n }\\\\n}\\\\n}\\\\n\\\\nconsole.log(\\\\\\\"after 3rd loop\\\\\\\");\\\\nconsole.log(nextVal);\\\\nconsole.log(nextValInv);\\\\nconsole.log(nextValNa);\\\\nconsole.log(hashmap);\\\\n\\\\n// file format config rule\\\\nfilemap.set('tiff', 'tiff');\\\\nfilemap.set('tif', 'tif');\\\\nfilemap.set('pdf', 'pdf');\\\\nfilemap.set('TIFF', 'TIFF');\\\\nfilemap.set('TIF', 'TIF');\\\\nfilemap.set('PDF', 'PDF'); \\\\n\\\\n\\\\nfor(var i=0;i<arr.length;i++){\\\\n console.log(\\\\\\\"inside format loop\\\\\\\");\\\\n //console.log(\\\\\\\"file name\\\\\\\"+arr[i].name);\\\\n //console.log(\\\\\\\"filelength\\\\\\\"+arr[i].name.length);\\\\n fileformat='';\\\\n //get format from filename\\\\n console.log(\\\\\\\"file name \\\\\\\"+arr[i].name);\\\\n if (arr[i].name === undefined) {\\\\n console.log(\\\\\\\"empty file name\\\\\\\");\\\\n \\tbreak;\\\\n }\\\\n var lastindex = arr[i].name.length-1;\\\\n console.log(\\\\\\\"lastindex \\\\\\\"+lastindex);\\\\n for(var j=lastindex;j>=0;j--){\\\\n if(arr[i].name[j]==='.')\\\\n break;\\\\n else{\\\\n fileformat += arr[i].name[j];\\\\n } \\t\\\\n }\\\\n fileformat = fileformat.split('').reverse().join('');\\\\n console.log(\\\\\\\"file format \\\\\\\"+fileformat);\\\\n //check if format present in map\\\\n if(!filemap.has(fileformat)){\\\\n //throw error\\\\n errorFormat.visible=true;\\\\n formatCheck=false;\\\\n //stop from moving next\\\\n console.log(\\\\\\\"invalid file attached\\\\\\\");\\\\n break;\\\\n }\\\\n}\\\\n\\\\n\\\\n//2nd button file\\\\nfor(var i=0;i<arrInv.length;i++){\\\\n console.log(\\\\\\\"inside format loop\\\\\\\");\\\\n //console.log(\\\\\\\"file name\\\\\\\"+arr[i].name);\\\\n //console.log(\\\\\\\"filelength\\\\\\\"+arr[i].name.length);\\\\n fileformat='';\\\\n //get format from filename\\\\n console.log(\\\\\\\"file name \\\\\\\"+arrInv[i].name);\\\\n if (arrInv[i].name === undefined) {\\\\n console.log(\\\\\\\"empty file name\\\\\\\");\\\\n \\tbreak;\\\\n }\\\\n var lastindex = arrInv[i].name.length-1;\\\\n console.log(\\\\\\\"lastindex \\\\\\\"+lastindex);\\\\n for(var j=lastindex;j>=0;j--){\\\\n if(arrInv[i].name[j]==='.')\\\\n break;\\\\n else{\\\\n fileformat += arrInv[i].name[j];\\\\n } \\t\\\\n }\\\\n fileformat = fileformat.split('').reverse().join('');\\\\n console.log(\\\\\\\"file format \\\\\\\"+fileformat);\\\\n //check if format present in map\\\\n if(!filemap.has(fileformat)){\\\\n //throw error\\\\n errorFormat.visible=true;\\\\n formatCheck=false;\\\\n //stop from moving next\\\\n console.log(\\\\\\\"invalid file attached\\\\\\\");\\\\n break;\\\\n }\\\\n}\\\\n\\\\n// 3rd button loop \\\\nfor(var i=0;i<arrNa.length;i++){\\\\n console.log(\\\\\\\"inside format loop\\\\\\\");\\\\n //console.log(\\\\\\\"file name\\\\\\\"+arr[i].name);\\\\n //console.log(\\\\\\\"filelength\\\\\\\"+arr[i].name.length);\\\\n fileformat='';\\\\n //get format from filename\\\\n console.log(\\\\\\\"file name \\\\\\\"+arrNa[i].name);\\\\n if (arrNa[i].name === undefined) {\\\\n console.log(\\\\\\\"empty file name\\\\\\\");\\\\n \\tbreak;\\\\n }\\\\n var lastindex = arrNa[i].name.length-1;\\\\n console.log(\\\\\\\"lastindex \\\\\\\"+lastindex);\\\\n for(var j=lastindex;j>=0;j--){\\\\n if(arrNa[i].name[j]==='.')\\\\n break;\\\\n else{\\\\n fileformat += arrNa[i].name[j];\\\\n } \\t\\\\n }\\\\n fileformat = fileformat.split('').reverse().join('');\\\\n console.log(\\\\\\\"file format \\\\\\\"+fileformat);\\\\n //check if format present in map\\\\n if(!filemap.has(fileformat)){\\\\n //throw error\\\\n errorFormat.visible=true;\\\\n formatCheck=false;\\\\n //stop from moving next\\\\n console.log(\\\\\\\"invalid file attached\\\\\\\");\\\\n break;\\\\n }\\\\n}\\\\n\\\\n\\\\n\\\\nif(nextVal && nextValInv && nextValNa && totalDocumentsAttached.value && formatCheck){\\\\nguideBridge.setFocus(wizardPanel.somExpression, \\\\\\\"nextItem\\\\\\\",true);\\\\n$(window).scrollTop(0);\\\\n}\\\\n} \\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\ntry {\\n eval(\\\"if((upload_medical_records_category.attachmentsHandler.attachments.attachment.fileName.value === null) && (upload_invoice_category.attachmentsHandler.attachments.attachment.fileName.value === null) && (no_category_attachments.attachmentsHandler.attachments.attachment.fileName.value === null)){\\\\n Noattachmentalert.visible = false; \\\\n textError.visible = true;\\\\n}else if((upload_medical_records_category.attachmentsHandler.attachments.attachment.fileName.value !== null) || (upload_invoice_category.attachmentsHandler.attachments.attachment.fileName.value !== null) || (no_category_attachments.attachmentsHandler.attachments.attachment.fileName.value === null)){\\\\n Noattachmentalert.visible = false;\\\\n textError.visible = false;\\\\n}else{\\\\n Noattachmentalert.visible = false;\\\\n textError.visible = false; \\\\n}\\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\\ntry {\\n eval(\\\"if(totalDocumentsAttached.value < 1){\\\\n errorMessageText.visible = true;\\\\n false;\\\\n}else if(totalDocumentsAttached.value > 0){\\\\n errorMessageText.visible = false;\\\\n} \\\");\\n \\n} catch (e) {\\n window.guideBridge._guide.logger().error(\\\"AF\\\",\\\"Failed to execute rule: \\\" + e);\\n}\\n\",\"nonLocalizedTitle\":\"Next\",\"cq:responsive\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav-cq:responsive__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/nextitemnav/cq:responsive\",\"default\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav-cq:responsive-default__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/nextitemnav/cq:responsive/default\",\"offset\":\"0\",\"width\":\"2\"}},\"style\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav-style__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/nextitemnav/style\",\"af_nextitemnavbutton\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel_1492325676_cop-nextitemnav-style-af_nextitemnavbutton__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel_1492325676_cop/items/nextitemnav/style/af_nextitemnavbutton\",\"default#focus\":[\"border-style:solid\",\"border-color:#000000\",\"color:#FFFFFF\",\"background:#666666\"],\"default#hover\":[\"background:#666666\",\"border-style:solid\",\"border-color:#111111\",\"color:#FFFFFF\"],\"default#default\":[\"border-style:solid\",\"margin-top:24px\"],\"default#hover#ui\":[\"backgroundColor:#666666\"],\"default#focus#ui\":[\"backgroundColor:#666666\"],\"default#default#ui\":[\"marginLock:linkOff\",\"marginPopover:24px, \\u2014, \\u2014, \\u2014\"]}}}}},\"panel\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel\",\"guideNodeClass\":\"guidePanel\",\"jcr:title\":\"Review and submit\",\"validateOnStepCompletion\":false,\"dorExcludeTitle\":\"true\",\"css\":\"noSummary\",\"name\":\"verify_Submit\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"fd/af/components/panel\",\"textIsRich\":\"true\",\"nonLocalizedTitle\":\"Review and submit\",\"layout\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel-layout__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/layout\",\"dorNumCols\":\"1\",\"toolbarPosition\":\"Bottom\",\"columns\":\"1\",\"sling:resourceType\":\"fd/af/layouts/gridFluidLayout2\",\"dorLayoutType\":\"columnar\",\"nonNavigable\":true},\"items\":{\"guidetextdraw\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/items/guidetextdraw\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<h2 style=\\\"font-size: 26.0px;\\\"><b>Review and submit<\\/b><\\/h2>\\n\",\"css\":\"noSummary\",\"name\":\"Heading\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_602855052\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel-guidetextdraw_602855052__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/items/guidetextdraw_602855052\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p>Fields marked with an asterisk * are required<\\/p>\\n\",\"name\":\"verifyInstructions\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"summarytemplate\":{\"templateId\":\"guideContainer-rootPanel-panel1617372512792-panel-summarytemplate__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/panel1617372512792/items/panel/items/summarytemplate\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p><b>Review the details below and make any changes before submitting your request<\\/b><\\/p>\\n\",\"name\":\"summarytemplate1631131568499\",\"dorExclusion\":\"true\",\"sling:resourceType\":\"dfa-optum/fd/af/components/summarytemplate\",\"textIsRich\":\"true\",\"placeholderText\":\"<table style=\\\"width:130%; text-align: left; table-layout: fixed; display:table-cell; word-wrap:break-word;\\\">\\r\\n {{for components}}\\r\\n {{if children}}\\r\\n {{if 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you for your submission!<\\/b><\\/p>\",\"name\":\"TU\",\"sling:resourceType\":\"fd/af/components/guidetextdraw\",\"textIsRich\":\"true\",\"documentFragmentVariables\":[]},\"guidetextdraw_688646357\":{\"templateId\":\"guideContainer-rootPanel-modalpanel-guidetextdraw_688646357__\",\"id\":\"\",\"jcr:path\":\"/content/forms/af/uhc/sharedservices/dfa/hedis/test-hedis-symplisend/jcr:content/guideContainer/rootPanel/items/modalpanel/items/guidetextdraw_688646357\",\"guideNodeClass\":\"guideTextDraw\",\"_value\":\"<p><b>Confirmation #:<\\/b> __CONFIRMATION__<br />\\n<\\/p>\\n<p><b>Submission date: 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</form>Text Content
QUALITY PROGRAMS WEB SUBMISSION - CHART DROP FORM
* Form Instructions
* Wizard panel
* Email verification
* Provider information
* Attachment details
* Review and submit
*
* We’re sorry
Form Instructions
For health care professionals of Quality Program File Submissions
--------------------------------------------------------------------------------
ESTIMATED TIME TO COMPLETE:
5 - 10 minutes
* This form is for health care professionals who are submitting medical records
to fulfill HEDIS ® and quality program requests
WHAT DO I NEED?
To complete this submission, you may be required to provide some or all of the
information:
* Group name
* Contact first and last name
* Return phone number in case there are questions or issues with the submission
* Reference # provided on the medical record request list
IMPORTANT THINGS TO KNOW BEFORE COMPLETING THE FORM
* Name medical records using the reference # on the medical record request list
(example reference # 44458135553)
* Files must be in either PDF, TIFF, or TIF format only. No other formats are
accepted. The system will give you a real-time notification if the format of
the uploaded document(s) is unacceptable.
* Do not submit password protected documents. This is a secure site and there
is no need for additional security measures.
Submit documents
Form UID
FormType
FormName
fdmPath
1. Email verification
0% Complete
2. Provider information
0% Complete
3. Attachment details
0% Complete
4. Review and submit
0% Complete
EMAIL VERIFICATION
All fields are required
Let's verify your contact information
Please enter your email address and select Send code. A code will be sent to the
email address entered to verify the address is valid. If you don’t get the
email, make sure the address you entered is correct or check your spam folder.
Enter email address (name@domain.com) *
Send code
response
Code sent. Please check your email for the code and enter it below.
Code expires after 6 hours and can only be utilized once.
Enter code *
Validate code
validateresponse
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Next
PROVIDER INFORMATION
Fields marked with an asterisk * are required.
Group name *
Enter provider group of physician who provided the service (examples: Mayo
Clinic, LabCorp, Primary Medical Group (PMG), Rite-Aid, CareMount Medical)
Contact first name *
Contact last name *
Phone number *
Comments
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Next
ATTACHMENT DETAILS
Documents should only be attached for members included in the request package
received from Quality Value Solutions Delivery for HEDIS® and other quality
programs.
Document Requirements:
* TIFF, TIF and/or PDF format only.
* Each document must only include one member. A separate document should be
uploaded for each member.
* Name medical records using the reference # provided on the medical record
request list (example # 44458135553).
* If uploading multiple documents for a single reference #, name the individual
documents as reference #_1, 2, 3, etc.
* Documents cannot be password protected or encrypted. This is a secure site
and there is no need for additional security measures.
Upload Requirements:
* Each document cannot exceed 200MB in size
* Do not upload more than 100 documents at a time.
Troubleshooting Suggestions:
* Upload in batches of 20 or less if you encounter delays with large files
successfully uploading.
If you have any questions or need further assistance uploading documents, please
contact us at (866) 808-6206 or at UHC_QSD_Collection@uhc.com.
Submission ID
Submission ID
Upload medical record(s)
Only medical records should be uploaded in this section. Each document must only
include one member. A separate document should be uploaded for each member.
The medical records should document the services rendered, such as progress
notes, lab results, etc.
Upload Attachment (Maximum 25mb per attachment).
Please select a category Category
Remove
Category
Upload medical records
Attached:
Extension
Upload invoice(s)
Invoices to cover the cost of medical record retrieval should be separated from
the medical record. If this is not possible, then upload the medical record in
conjunction with the invoice in this section. Please note: Uploading combined
documents will delay the payment of the invoice. Please do not submit invoices
for anything other than medical record retrieval fees.
Upload Attachment (Maximum 25mb per attachment).
Please select a category Category
Remove
Category
Upload invoices
Attached:
Extension
Chart not available document(s)
If you receive a request for a member(s) who was not your patient or no services
were rendered during the requested timeframe, please upload the medical record
list with the appropriate box checked to state the reason the information
requested is not available.
Upload Attachment (Maximum 25mb per attachment).
Please select a category Category
Remove
Category
Upload other
Attached:
Extension
Error: Please upload at least one document
Invalid file formats attached - please remove
Error: A duplicate document has been uploaded. Please remove the duplicate
document.
Total Documents Attached
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Next
REVIEW AND SUBMIT
Fields marked with an asterisk * are required
Review the details below and make any changes before submitting your request
AGREE AND SIGN
Do not eSign until you scroll, read, and agree to the below terms and conditions
From time to time, United Healthcare Services, Inc., or their affiliates,
subsidiaries, agents, contractors, or vendors (we or us) may be required by law
to provide to you certain written notices or disclosures. Please read the
information below carefully and agree to this Electronic Record nd Signature
Disclosure (ERSD). Please confirm your agreement by selecting the check-box next
to ‘I agree to use electronic records and signatures’ before signing this
document.
Getting paper copies
At any time, you may request a paper copy of any record provided or made
available electronically to you by us. You will have the ability to download and
print documents we send to you during and immediately after this signing
session.
Acknowledging your access and consent to receive and sign documents
electronically
By selecting the check-box next to ‘I agree to use electronic records and
signatures’, you confirm that:
• You intend to sign the document electronically.
• You can access and read this Electronic Record and Signature Disclosure.
• You can print on paper this Electronic Record and Signature Disclosure, or
save or send this Electronic Record and Disclosure to a location where you can
print it, for future reference and access.
• You acknowledge that emails containing your protected health information will
be sent unencrypted and there is a risk of interception or disclosure of the
contents of the emails.
By selecting Adopt and Sign, I agree that the signature and initials will be the
electronic representation of my signature and initials for all purposes when I
(or my agent) use them on documents, including legally binding contracts - just
the same as a pen-and-paper signature or initial
By signing below, I am stating that the information above is correct. Any person
who knowingly files a statement of claim containing any misrepresentation or any
false, incomplete or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties.
By checking this box and signing below, I acknowledge that I have read,
understand and agree to all of the above.*
Note: You need to scroll through the information above before you can check the
box.
By signing my eSignature below, I am attesting that I have read and understand
the below statements. I acknowledge that my eSignature is the electronic
equivalent of a hand-written signature. By signing the upload submission, you
are authorizing United Healthcare to utilize the documents in accordance with
our quality programs and regulatory guidelines, you are not attesting to the
accuracy of the content provided within the medical records.
Submitter signature *
Submission date *
Once this form is submitted, the provided forms are final and they can not be
retracted. You will receive an immediate response if the upload is
unsuccessful. An email confirmation will be sent with the Submission ID number
for your records and tracking purposes following successful submission.
Back
Submit
NewSubmit
Submit
remainingAttempts
Thank you for your submission!
Confirmation #: __CONFIRMATION__
Submission date: __SUBMIT_DATE__
An email confirmation will be sent with the confirmation number for your
records.
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WE’RE SORRY
Looks like something went wrong. We're sorry about that. Here are some details:
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