forms.patientconnect365.com
Open in
urlscan Pro
2620:1ec:bdf::40
Public Scan
Submitted URL: http://email.patientconnect365.com/ls/click?upn=gGObSRTNM-2BfL8byDNSKMIYFZRH0EysCLHTxjYj3bDYg-3D-zJA_ycFUGOmj-2BzZRMCTo5aRQsYV5k0iP...
Effective URL: https://forms.patientconnect365.com/3975/form/118974164
Submission: On March 31 via manual from US — Scanned from US
Effective URL: https://forms.patientconnect365.com/3975/form/118974164
Submission: On March 31 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
POST /3975/form/118974164/SaveInsuranceInfo
<form action="/3975/form/118974164/SaveInsuranceInfo" method="post" class="steps-form" style="">
<div class="inner-box">
<h3 class="title-h3">
<span class="text-gray">Form: </span>Insurance Info
</h3>
<ol class="b-steps b-grid-wrap">
<li class="b-grid-wrap__box--size-25">
<a class="b-steps__step b-steps__step--active">Primary Insurance</a>
</li>
<li class="b-grid-wrap__box--size-25">
<a class="b-steps__step ">Secondary Insurance</a>
</li>
<li class="b-grid-wrap__box--size-25">
<a class="b-steps__step ">Confirm</a>
</li>
</ol>
</div>
<div id="patient-info" class="inner-box" data-role="section">
<h3 class="title-h3">Patient Information</h3>
<div class="b-inner-form b-grid-wrap b-grid-wrap--offset">
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="FirstName">FIRST Name</label>
<input type="text" id="FirstName" name="FirstName" value="" data-role="value" data-type="text" class="b-inner-form__input" data-required="" maxlength="40">
<span class="validation-message" data-role="validation-message" data-target="FirstName"></span>
</div>
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="LastName">LAST Name</label>
<input type="text" id="LastName" name="LastName" value="" data-role="value" data-type="text" class="b-inner-form__input" data-required="" maxlength="40">
<span class="validation-message" data-role="validation-message" data-target="LastName"></span>
</div>
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="MiddleInitial">MI</label>
<input type="text" id="MiddleInitial" name="MiddleInitial" value="" data-role="value" data-type="text" class="b-inner-form__input b-inner-form__input--xs" maxlength="2">
<span class="validation-message" data-role="validation-message" data-target="MiddleInitial"></span>
</div>
</div>
</div>
<div id="insurance-info">
<div id="insurance-have" class="inner-box" data-role="section">
<h3 class="title-h3">Do you have dental insurance or will you be paying for yourself?</h3>
<div class="b-grid-wrap">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap">
<label class="b-inner-form__label" for="field-primary_have"></label>
<select class="jcf-hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_have" name="field-primary_have">
<option value="">Please Choose</option>
<option value="1">I have dental Insurance</option>
<option value="0">I will pay for myself</option>
</select><span class="jcf-select jcf-unselectable"><span class="jcf-select-text"><span class="">Please Choose</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message" data-role="validation-message" data-target="field-primary_have"></span>
</div>
</div>
</div>
<div id="insurance-company" class="inner-box hidden" data-role="section">
<h3 class="title-h3">Primary Dental Insurance - Insurance Company</h3>
<div class="b-grid-wrap b-grid-wrap--offset hidden">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_plan">Type of Plan</label>
<select class="jcf-hidden hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_plan" name="field-primary_plan">
<option value="">Please Choose</option>
<option value="0">Dental Insurance</option>
<option value="1">Medicaid</option>
<option value="2">Other</option>
</select><span class="jcf-select jcf-unselectable"><span class="jcf-select-text"><span class="">Please Choose</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_plan"></span>
</div>
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_companyname">Insurance Company Name</label>
<input type="text" id="field-primary_companyname" name="field-primary_companyname" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="Enter Company Name" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_companyname"></span>
</div>
</div>
<div class="b-grid-wrap hidden">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_insuranceid">Subscriber ID</label>
<input type="text" id="field-primary_insuranceid" name="field-primary_insuranceid" data-role="value" data-type="text" maxlength="25" class="b-inner-form__input hidden" data-required="" placeholder="Enter Subscriber ID" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_insuranceid"></span>
</div>
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_groupid">Group #</label>
<input type="text" id="field-primary_groupid" name="field-primary_groupid" data-role="value" data-type="text" maxlength="25" class="b-inner-form__input hidden" data-required="" placeholder="Enter Group #" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_groupid"></span>
</div>
</div>
</div>
<div id="insurance-insured" class="inner-box hidden" data-role="section">
<h3 class="title-h3">Primary Dental Insurance - Insured</h3>
<div class="b-grid-wrap b-grid-wrap--offset hidden">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_relationship">Relationship to Patient</label>
<select class="jcf-hidden hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_relationship" name="field-primary_relationship">
<option value="">Please Choose</option>
<option value="0">Self</option>
<option value="1">Parent</option>
<option value="2">Spouse</option>
<option value="3">Guardian</option>
<option value="4">Other</option>
</select><span class="jcf-select jcf-unselectable"><span class="jcf-select-text"><span class="">Please Choose</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_relationship"></span>
</div>
</div>
<div class="b-grid-wrap b-grid-wrap--offset hidden" data-role="section">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_firstname">FIRST Name</label>
<input type="text" id="field-primary_firstname" name="field-primary_firstname" data-role="value" data-type="text" maxlength="50" class="b-inner-form__input hidden" data-required="" placeholder="Enter FIRST Name" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_firstname"></span>
</div>
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_lastname">LAST Name</label>
<input type="text" id="field-primary_lastname" name="field-primary_lastname" data-role="value" data-type="text" maxlength="50" class="b-inner-form__input hidden" data-required="" placeholder="Enter LAST Name" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_lastname"></span>
</div>
</div>
<div class="b-grid-wrap b-grid-wrap--offset hidden">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_dob">Birth Date</label>
<div class="b-inner-form__date">
<input type="number" pattern="\d*" data-role="month" placeholder="MM" class="b-inner-form__input b-inner-form__input--xs" maxlength="2">
<input type="number" pattern="\d*" data-role="day" placeholder="DD" class="b-inner-form__input b-inner-form__input--xs" maxlength="2">
<input type="number" pattern="\d*" data-role="year" placeholder="YYYY" class="b-inner-form__input" maxlength="4">
</div>
<input type="hidden" id="field-primary_dob" name="field-primary_dob" data-role="value" data-type="date" data-required="" class="hidden">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_dob"></span>
</div>
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_ssn">Social Security #</label>
<input type="tel" name="field-primary_ssn" data-role="value" data-type="ssn" maxlength="11" class="b-inner-form__input hidden" data-required="" placeholder="Enter Soc Sec #" autocomplete="off" style="display: none;"><input type="tel"
data-type="ssn" maxlength="11" class="b-inner-form__input" data-required="" placeholder="Enter Soc Sec #" autocomplete="off" style="display: none;"><input type="tel" id="field-primary_ssn" data-type="ssn" maxlength="11"
class="b-inner-form__input" data-required="" placeholder="Enter Soc Sec #" autocomplete="off">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_ssn"></span>
</div>
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_dl">Drivers License</label>
<input type="text" id="field-primary_dl" name="field-primary_dl" data-role="value" data-type="driverlicense" maxlength="20" class="b-inner-form__input hidden" placeholder="DL #" autocomplete="off">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_dl"></span>
</div>
</div>
<div class="b-grid-wrap b-grid-wrap--offset hidden">
<div class="b-grid-wrap__box--size-50">
<div class="b-inner-form__input-wrap b-inner-form__inputs-set hidden">
<label> Address <label class="b-inner-form__label hidden" for="field-primary_address1"></label>
<input type="text" id="field-primary_address1" name="field-primary_address1" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="Address 1" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_address1"></span>
</label>
<label class="b-inner-form__label hidden" for="field-primary_address2"></label>
<input type="text" id="field-primary_address2" name="field-primary_address2" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" placeholder="Address 2" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_address2"></span>
<div class="b-inner-form__inputs-group">
<label class="b-inner-form__label hidden" for="field-primary_city"></label>
<input type="text" id="field-primary_city" name="field-primary_city" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="City" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_city"></span>
<label class="b-inner-form__label hidden" for="field-primary_state"></label>
<select class="xs jcf-hidden hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_state" name="field-primary_state">
<option value="">State</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select><span class="jcf-select jcf-unselectable jcf-select-xs"><span class="jcf-select-text"><span class="">State</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_state"></span>
<label class="b-inner-form__label hidden" for="field-primary_zip"></label>
<input type="text" id="field-primary_zip" name="field-primary_zip" data-role="value" data-type="zip" maxlength="10" class="b-inner-form__input b-inner-form__input--sm hidden" data-required="" placeholder="Zip" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_zip"></span>
</div>
</div>
</div>
</div>
</div>
<div id="insurance-employer" class="inner-box hidden" data-role="section">
<h3 class="title-h3">Primary Dental Insurance - Employer</h3>
<div class="b-grid-wrap b-grid-wrap--offset hidden">
<div class="b-grid-wrap__box--size-25 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_employer_isthrough">Is the plan through an employer?</label>
<select class="jcf-hidden hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_employer_isthrough" name="field-primary_employer_isthrough">
<option value="">Please Choose</option>
<option value="1">Yes</option>
<option value="0">No</option>
</select><span class="jcf-select jcf-unselectable"><span class="jcf-select-text"><span class="">Please Choose</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_isthrough"></span>
</div>
</div>
<div class="b-grid-wrap b-grid-wrap--offset hidden" data-role="section">
<div class="b-grid-wrap__box--size-50 b-inner-form__input-wrap hidden">
<label class="b-inner-form__label hidden" for="field-primary_employer_companyname">Employer Company Name</label>
<input type="text" id="field-primary_employer_companyname" name="field-primary_employer_companyname" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="Enter Company Name"
autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_companyname"></span>
</div>
</div>
<div class="b-grid-wrap b-grid-wrap--offset hidden" data-role="section">
<div class="b-grid-wrap__box--size-50">
<div class="b-inner-form__input-wrap b-inner-form__inputs-set hidden">
<label class="b-inner-form__label hidden" for="field-primary_employer_address1">Employer Address</label>
<input type="text" id="field-primary_employer_address1" name="field-primary_employer_address1" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="Address 1" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_address1"></span>
<label class="b-inner-form__label hidden" for="field-primary_employer_address2"></label>
<input type="text" id="field-primary_employer_address2" name="field-primary_employer_address2" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" placeholder="Address 2" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_address2"></span>
<div class="b-inner-form__inputs-group">
<label class="b-inner-form__label hidden" for="field-primary_employer_city"></label>
<input type="text" id="field-primary_employer_city" name="field-primary_employer_city" data-role="value" data-type="text" maxlength="100" class="b-inner-form__input hidden" data-required="" placeholder="City" autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_city"></span>
<label class="b-inner-form__label hidden" for="field-primary_employer_state"></label>
<select class="xs jcf-hidden hidden" data-required="" data-role="value" data-type="dropdown" id="field-primary_employer_state" name="field-primary_employer_state">
<option value="">State</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select><span class="jcf-select jcf-unselectable jcf-select-xs"><span class="jcf-select-text"><span class="">State</span></span><span class="jcf-select-opener"></span></span>
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_state"></span>
<label class="b-inner-form__label hidden" for="field-primary_employer_zip"></label>
<input type="text" id="field-primary_employer_zip" name="field-primary_employer_zip" data-role="value" data-type="zip" maxlength="10" class="b-inner-form__input b-inner-form__input--sm hidden" data-required="" placeholder="Zip"
autocomplete="">
<span class="validation-message hidden" data-role="validation-message" data-target="field-primary_employer_zip"></span>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="btn-holder">
<div class="buttons-box">
</div>
<button type="submit" class="btn-link btn-link__blue btn-link--sm" data-role="next">NEXT</button>
</div>
</form>Text Content
FORM: INSURANCE INFO 1. Primary Insurance 2. Secondary Insurance 3. Confirm PATIENT INFORMATION FIRST Name LAST Name MI DO YOU HAVE DENTAL INSURANCE OR WILL YOU BE PAYING FOR YOURSELF? Please Choose I have dental Insurance I will pay for myself Please Choose PRIMARY DENTAL INSURANCE - INSURANCE COMPANY Type of Plan Please Choose Dental Insurance Medicaid Other Please Choose Insurance Company Name Subscriber ID Group # PRIMARY DENTAL INSURANCE - INSURED Relationship to Patient Please Choose Self Parent Spouse Guardian Other Please Choose FIRST Name LAST Name Birth Date Social Security # Drivers License Address State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY State PRIMARY DENTAL INSURANCE - EMPLOYER Is the plan through an employer? Please Choose Yes No Please Choose Employer Company Name Employer Address State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY State NEXT © Copyright 2022 PatientConnect365 * Privacy Policy * Terms of Use * Contact Us California Dental Care & Orthodontics, 9275 Baseline Road, Rancho Cucamonga, CA 91730 Phone (appointments): 909-945-0024 powered by PatientConnect365