webchartnow.com
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64.186.39.20
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URL:
https://webchartnow.com/ohiohealth/webchart.cgi?f=layout&pat_id=177077&module=Patient+Portal&name=Home&svar_cobrand_pati...
Submission: On July 08 via manual from US — Scanned from DE
Submission: On July 08 via manual from US — Scanned from DE
Form analysis
2 forms found in the DOMName: login_form — POST webchart.cgi
<form name="login_form" id="login_form" action="webchart.cgi" method="post" style="display: none;">
<input type="hidden" name="f" value="layout">
<input type="hidden" name="pat_id" value="177077">
<input type="hidden" name="module" value="Patient Portal">
<input type="hidden" name="name" value="Home">
<input type="hidden" name="svar_cobrand_patid" value="35548">
<input type="hidden" name="actcode" value="D9KM5CPCRZVV">
<input type="hidden" name="login_post_redirect_get">
<div class="login_input_container">
<div id="login_user_field" class="input-container has-error-msg">
<div class="invalid-tooltip">username is invalid</div>
<input type="text" name="login_user" id="login_user" class="float-label" size="15" maxlength="255" autocomplete="off" onchange="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true);">
<label for="login_user">Username</label>
<span>Forgot your <a href="webchart.cgi?f=login&s=ulookup">username</a>?</span>
</div>
<div id="login_pass_field" class="input-container has-error-msg">
<div class="invalid-tooltip">password is invalid</div>
<input tabindex="-1" type="password" name="login_passwd" id="login_passwd" class="float-label" autocomplete="off" onchange="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true);" size="15" maxlength="50">
<label for="login_passwd">Password</label>
<span>Forgot your <a tabindex="-1" href="webchart.cgi?f=login&s=preset">password</a>?</span>
</div>
</div>
<div class="form-footer form-footer-lg">
<input type="submit" value="Next" name="login_submit" id="login_submit" class="primary-bg">
<button id="referral-open"><span class="fa fa-user-plus" title="Create account" aria-hidden="true"></span> <span class="sr-only">Create account</span> Create account</button>
<button class="prev-stage"><span class="fa fa-arrow-left" title="Return to login" aria-hidden="true"></span> <span class="sr-only">Return to login</span> Back</button>
</div>
</form>
Name: referral_form —
<form name="referral_form" id="referral_form" style="display: block;">
<input type="hidden" name="f" value="ajaxregister">
<input type="hidden" name="unpw" value="1">
<input type="hidden" name="termschecked" value="1">
<input type="hidden" name="promobdate">
<input type="hidden" name="svar_cobrand_patid" value="35548">
<div class="referral_input_container advance">
<div>
<div id="login_promo_field" class="input-container has-error-msg">
<div class="invalid-tooltip">activation code could not be validated</div>
<input type="text" name="mrnumber" id="referral_code" value="D9KM5CPCRZVV" class="float-label filled" size="15" maxlength="50" onkeyup="if (this.value.length >=12) checkReferral();" onchange="if (this.value.length >=12) checkReferral();">
<label for="referral_code">Activation code</label>
</div>
<div id="dob-container" class="input-container has-error-msg" style="visibility:hidden">
<div class="invalid-tooltip show-error">date of birth is invalid</div>
<label id="dob-label" for="DPD_birth_dateMONTH">Date of birth</label>
<input type="hidden" name="DPFN_birth_date" value="birth_date" disabled="" tabindex="-1"><input type="hidden" name="DPI_birth_date" value="~DATE" disabled="" tabindex="-1"><span class="dateinput"><span class="date">
<div class="dob-input-container"><input type="text" class="month invalid float-label" autocomplete="off" name="DPD_birth_dateMONTH" id="DPD_birth_dateMONTH" maxlength="2" title="Month"
onblur="if(window.jsFormatInputs) formatDateM(this, 'month', 0, 1, event)" onkeydown="if(window.jsFormatInputs) incrementDateM(this, event, 'month', 0, 1)" onfocus="this.select();"
onkeypress="if(window.jsFormatInputs) return handleKeyPressNS(this, event, 1,'month','',1)" onkeyup="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true);if(window.jsFormatInputs) handleKeyUpNS(this,1,event)"
onclick="if(window.jsFormatInputs) {}" disabled="" tabindex="-1"><label id="month-label" for="DPD_birth_dateMONTH">MM</label></div>-<div class="dob-input-container"><input type="text" class="day invalid float-label" autocomplete="off"
name="DPD_birth_dateDAY" id="DPD_birth_dateDAY" maxlength="2" title="Day" onblur="if(window.jsFormatInputs) formatDateM(this, 'day', 0, 1, event)" onkeydown="if(window.jsFormatInputs) incrementDateM(this, event, 'day', 0, 1)"
onkeypress="if(window.jsFormatInputs) return handleKeyPressNS(this, event, 1,'day','',1)" onfocus="this.select();"
onkeyup="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true);if(window.jsFormatInputs) handleKeyUpNS(this,1,event)" onclick="if(window.jsFormatInputs) {}" disabled="" tabindex="-1"><label id="day-label"
for="DPD_birth_dateDAY">DD</label></div>-<div class="dob-input-container"><input type="text" class="year invalid float-label" autocomplete="off" name="DPD_birth_dateYEAR" id="DPD_birth_dateYEAR" maxlength="4" title="Year"
onkeydown="if(window.jsFormatInputs) incrementDateM(this, event, 'year', 0, 1)" onblur="if(window.jsFormatInputs) formatDateM(this, 'year', 0, 1, event)" onfocus="this.select();"
onkeypress="if(window.jsFormatInputs) return handleKeyPressNS(this, event, 1,'year','',1)" onkeyup="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true);if(window.jsFormatInputs) handleKeyUpNS(this,1,event)"
onclick="if(window.jsFormatInputs) {}" disabled="" tabindex="-1"><label id="year-label" for="DPD_birth_dateYEAR">YYYY</label></div><button type="button" class="fa" id="DPD_birth_dateTODAY" title="Today"
onclick="if (window.setCheckonUnloadFlag) setCheckonUnloadFlag(true); if(window.jsFormatInputs) getTodayM('DPD_birth_date', 0, 1, this.form, event);" disabled="" tabindex="-1"></button>
</span><button type="button" id="DPD_birth_date_link" class="fa" title="Calendar" onclick="if(window.jsFormatInputs) { ClickPickDate(this,'DPD_birth_dateMONTH','DPD_birth_date_cal','DPD_birth_date_link',false,1,true); }"
aria-label="Calendar" disabled="" tabindex="-1"></button></span>
</div>
</div>
<div id="referral-accepted-stage">
<div class="form-alert primary-bg" id="link-alert">
<span class="fa fa-user-circle" title="The referral code you entered is linked to this individual." aria-hidden="true"></span> <span class="sr-only">The referral code you entered is linked to this individual.</span> <span
id="referral-link-name">Cheryl Costeelo</span>
</div>
<div class="input-container">
<div id="referral_self_check">
<span id="reg-type-label">Who is this activation code for?</span>
<div>
<input class="toggle-reg-type" type="radio" id="reg-self" name="is_self" value="1" checked="">
<label for="reg-self">myself</label>
</div>
<div>
<input class="toggle-reg-type" type="radio" id="reg-other" name="is_self" value="0">
<label for="reg-other">someone else</label>
</div>
</div>
<div class="reg-other-input has-error-msg">
<div class="invalid-tooltip">first name is invalid</div>
<input type="text" name="first_name" id="first_name" class="float-label" size="15" maxlength="255" disabled="">
<label for="first_name">Your first name</label>
</div>
<div class="reg-other-input has-error-msg">
<div class="invalid-tooltip">last name is invalid</div>
<input type="text" name="last_name" id="last_name" class="float-label" size="15" maxlength="255" disabled="">
<label for="last_name">Your last name</label>
</div>
<div class="has-error-msg">
<div class="invalid-tooltip">email is invalid</div>
<input type="text" name="email" id="referral_email" class="float-label" size="15" maxlength="255">
<label for="referral_email">Email</label>
</div>
<div class="has-help has-error-msg">
<div id="user-help">
<span class="fa fa-question-circle" title="Username Help" aria-hidden="true"></span> <span class="sr-only">Username Help</span>
</div>
<div class="invalid-tooltip">username is invalid</div>
<input type="text" name="reg_user" id="referral_user" class="float-label" size="15" maxlength="15">
<label for="referral_user">Username</label>
</div>
<div class="has-help has-error-msg">
<div id="pass-help">
<span class="fa fa-question-circle" title="Password Help" aria-hidden="true"></span> <span class="sr-only">Password Help</span>
</div>
<div class="invalid-tooltip">password is invalid</div>
<input type="password" name="reg_passwd" id="referral_passwd" class="float-label" size="15" maxlength="50">
<label for="referral_passwd">Password</label>
</div>
<div class="has-error-msg">
<div class="invalid-tooltip">passwords do not match</div>
<input type="password" name="password" id="referral_confirm_passwd" class="float-label" size="15" maxlength="50">
<label for="referral_confirm_passwd">Confirm password</label>
</div>
</div>
</div>
</div>
<div class="form-footer form-footer-lg" id="form-server">
<div id="server-msg-container"><span class="fa fa-exclamation-triangle" title="Error" aria-hidden="true"></span> <span class="sr-only">Error</span><span id="server-msg"></span></div>
<input type="submit" value="Next" name="referral_submit" id="referral_submit" class="primary-bg">
<button class="prev-stage" style="display: inline-block;"><span class="fa fa-arrow-left" title="Return to login" aria-hidden="true"></span> <span class="sr-only">Return to login</span> Back</button>
</div>
</form>
Text Content
WELCOME OhioHealth Login Options Login Options OhioHealth Associate SignOn Employer Portal Login Create account Create account username is invalid Username Forgot your username? password is invalid Password Forgot your password? Create account Create account Return to login Back activation code could not be validated Activation code date of birth is invalid Date of birth MM - DD - YYYY The referral code you entered is linked to this individual. Cheryl Costeelo Who is this activation code for? myself someone else first name is invalid Your first name last name is invalid Your last name email is invalid Email Username Help username is invalid Username Password Help password is invalid Password passwords do not match Confirm password Error Return to login Back For help with your account, please contact OhioHealth Service Desk 614-566-HELP (4357). Enterprise Health Confidentiality and Non-Disclosure Agreement You are about to access patients' protected health information (PHI). The system should only be accessed by authorized users. By logging in and accessing PHI, you acknowledge that you are doing so in accordance with HIPAA and your organization's policies and procedures. Access is monitored and you will be held accountable for any activity on your login. Organizational information may include, but is not limited to, financial, patient identifiable, employee identifiable, intellectual property, financially non-public, contractual, of a competitive advantage nature, and from any source or in any form (i.e. paper, magnetic or optical media, conversations, film, etc.), may be considered confidential. Information's confidentiality and integrity are to be preserved and its availability maintained. The value and sensitivity of information is protected by law and by the strict policies of your organization. The intent of these laws and policies are to assure the confidential information will remain confidential through its use, only as a necessity to accomplish your organization's mission. © 2022 Enterprise Health, All rights reserved Privacy Policy Terms and Conditions