www.ltc-claims.com Open in urlscan Pro
206.83.162.194  Public Scan

Form analysis
1 forms found in the DOM

POST

<form id="pdfUpload" class="form-horizontal" method="POST" action="" enctype="multipart/form-data">
  <div class="form-group">
    <label class="col-3" for="idNo">Provider ID Number:</label>
    <div class="col-4">
      <input type="text" maxlength="10" class="form-control" id="idNo" name="idNo" data-event="" onkeypress="return isNumberKey(event);" aria-required="true">
    </div>
    <div id="idNoInfo" class="col-5 info">This is a unique number assigned by Long Term Care Claims. If you don't know your provider ID, please call Claims at 888-988-3772.</div>
  </div>
  <div id="emailUpload" class="form-group">
    <div class="col-3">
      <label>Select a Transaction:</label>
      <div><i>(Select all that apply.)</i></div>
    </div>
    <div class="col-4">
      <div class="radio">
        <input type="radio" id="registerEmail" name="transaction" value="Register New Email Address">
        <label for="registerEmail">Register New Email Address</label><br>
      </div>
      <div class="radio">
        <input type="radio" id="updateEmail" name="transaction" value="Update Existing Email Address">
        <label for="updateEmail">Update Existing Email Address</label><br>
      </div>
    </div>
    <div id="emailUploadInfo" class="col-5 info">Disclaimer: The primary email address will be used to send the Confinement Verification Form on a monthly basis. If an issue occurs with the primary email address, we will utilize the alternate email
      address to contact you.</div>
    <div class="col-3">&nbsp;</div>
    <div id="emailForm" class="col-4"></div>
  </div>
  <div id="grecapt" data-tabindex="5">
    <div style="width: 304px; height: 78px;">
      <div><iframe title="reCAPTCHA"
          src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LeDiuEaAAAAAEO4woJahjHW2EPO_nyVGmzthdTO&amp;co=aHR0cHM6Ly93d3cubHRjLWNsYWltcy5jb206NDQz&amp;hl=en&amp;v=Eyd0Dt8h04h7r-D86uAD1JP-&amp;size=normal&amp;cb=9ww5b49ubrwu" width="304"
          height="78" role="presentation" name="a-u3dkq6jphg67" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
      <textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
    </div><iframe style="display: none;"></iframe>
  </div>
  <div style="display:none" class="alert alert-success col-6" role="alert"></div>
  <br>
  <div id="agreement" class="form-group">
    <div class="col-12">
      <div class="checkbox">
        <label for="agreementCb"><input type="checkbox" id="agreementCb" name="agreementCb"> <span id="agreementLb">By clicking "Submit," I have the authority to agree and further agree to have the Confinement Verification Forms, as well as other
            communications as Long Term Care Claims Services sees fit, electronically sent to my entity's email addresses provided by me. I also agree to advise Long Term Care Claims Services if the email addresses provided can no longer receive
            electronic communications. Last, I acknowledge and agree to the Terms of Use and have read the Privacy Policy.</span></label>
      </div>
    </div>
  </div>
  <br>
  <div id="submitterName" class="form-group">
    <label class="col-3" for="submitterFirstName">Submitter’s Name:</label>
    <div class="col-4">
      <input type="text" placeholder="Your First Name" maxlength="128" class="form-control submitter" id="submitterFirstName" name="submitterFirstName" data-event="" aria-required="true">
    </div>
    <div class="col-4">
      <input type="text" placeholder="Your Last Name" maxlength="128" class="form-control submitter" id="submitterLastName" name="submitterLastName" data-event="" aria-required="true">
    </div>
  </div>
  <div id="field-error" class="form-group">
    <div id="submitterInfo" class="col-5 info"></div>
  </div>
  <div class="form-group">
    <div id="displayArea" class="col-3">
      <input type="submit" tabindex="6" id="submitBtn" class="btn btn-primary" disabled="disabled" value="Submit">
    </div>
    <div id="submitArea" class="col-3" style="display:none">
      <input type="submit" tabindex="6" id="submitBtn" class="btn btn-primary" disabled="disabled" value="Submit">
    </div>
    <div id="uploadingArea" class="col-5" style="display:none">
      <div class="col-8">
        <div class="loading"> Uploading </div>
      </div>
      <div class="col-4">
        <!--button id="cancelBtn" class="btn btn-regressive">Cancel</button-->
      </div>
    </div>
    <!--div id="successArea" class="col-6" style="display:none">
                        <div class="col-6"><button tabindex="7" id="resubmitBtn" class="btn btn-primary">Submit Another
                                Document</button></div>
                        <div class="col-1"></div>
                        <div class="col-5"><button tabindex="8" id="printBtn" class="btn btn-secondary"><i class="fa fa-print"
                                    aria-hidden="true"></i> Print this Page</button></div>
                    </div-->
    <div style="clear:both;"></div>
    <div class="disclaimer">
      <div>Long Term Care Claims Services provides claims services on behalf of the following insurance companies: Genworth Life Insurance Company, Genworth Life and Annuity Insurance Company, and Genworth Life Insurance Company of New York*.</div>
      <div style="font-size: 10px"><span>*</span>Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.</div><br>
      <p><span><i class="fa fa-lock" aria-hidden="true"></i> Your information is SECURE.</span> &nbsp;&nbsp;We use encryption and authentication tools to protect information we gather on our web site.</p>
    </div>
  </div>
</form>

Text Content

PROVIDERS - REGISTER EMAIL CONTACT INFORMATION




LONG TERM CARE CLAIMS SERVICES

Address: PO Box 40007
Lynchburg, VA 24506-9939
Phone:  888-988-3772

This page is for each provider to register primary and alternate email
address(es), as necessary, to receive electronic communications from Long Term
Care Claims Services. These electronic communications include Confinement
Verification Forms to be completed by your entity. It is important that you
provide email addresses of individuals who have the authority to submit these
types of forms on your entity's behalf. Please revisit this site to update email
addresses, as necessary.





ENTER PROVIDER ID

Provider ID Number:

This is a unique number assigned by Long Term Care Claims. If you don't know
your provider ID, please call Claims at 888-988-3772.
Select a Transaction:
(Select all that apply.)
Register New Email Address

Update Existing Email Address

Disclaimer: The primary email address will be used to send the Confinement
Verification Form on a monthly basis. If an issue occurs with the primary email
address, we will utilize the alternate email address to contact you.
 




By clicking "Submit," I have the authority to agree and further agree to have
the Confinement Verification Forms, as well as other communications as Long Term
Care Claims Services sees fit, electronically sent to my entity's email
addresses provided by me. I also agree to advise Long Term Care Claims Services
if the email addresses provided can no longer receive electronic communications.
Last, I acknowledge and agree to the Terms of Use and have read the Privacy
Policy.

Submitter’s Name:



Uploading


Long Term Care Claims Services provides claims services on behalf of the
following insurance companies: Genworth Life Insurance Company, Genworth Life
and Annuity Insurance Company, and Genworth Life Insurance Company of New York*.
*Only Genworth Life Insurance Company of New York is admitted in and conducts
business in New York.


Your information is SECURE.   We use encryption and authentication tools to
protect information we gather on our web site.

184005 07/21/21

 * Privacy
 * Terms Of Use


© 2021