spectrumhealth.patientwallet.com
Open in
urlscan Pro
18.239.50.36
Public Scan
Submitted URL: https://www.spectrumhealth.patientwallet.com/
Effective URL: https://spectrumhealth.patientwallet.com/
Submission: On October 18 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://spectrumhealth.patientwallet.com/
Submission: On October 18 via automatic, source certstream-suspicious — Scanned from DE
Form analysis
22 forms found in the DOMName: forms.verifyAcctForm —
<form name="forms.verifyAcctForm" novalidate="novalidate">
<h2 class="modal-header h-style-2"></h2>
<h3 class="modal-subheader h-style-4"></h3>
<div class="interaction-feedback" style="display: none;"></div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><input type="text" pastdate="" required="required" maxlength="10" autocomplete="off" name="birthdate" placeholder="Date of Birth (MM/DD/YYYY)" class="fs-block"></div>
<div class="input-area-feedback">
<div style="display: none;"><!----></div>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><input type="text" name="SSN" required="required" minlength="4" maxlength="4" inputmode="decimal" placeholder="Last Four Digits of Social Security Number" autocomplete="off" class="fs-block"></div>
<div class="input-area-feedback">
<div class="vue-messages"><!----></div>
</div>
</div>
<div class="SSN-help-text explanation-text" style="display: none;"><b>Note:</b> If you're adding accounts for an infant, use the guarantor's SSN</div><button class="button-primary button-callout submit-button"></button>
</form>
Name: forms.changePasswordForm —
<form name="forms.changePasswordForm" novalidate="novalidate"><!---->
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="current-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="currentPassword" type="password" maxlength="255" id="change-current-pass" placeholder="Current Password" tabindex="1" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper login-password-input-area">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="new-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="password" type="password" maxlength="255" id="new-pass" placeholder="New Password" tabindex="2" class="fs-block input-with-icon"></div>
<div class="input-area-rules">
<ul>
<li class="rule-met"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 8 characters </li>
<li class="rule-met"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 1 uppercase letter </li>
<li class="rule-met"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 1 number </li>
</ul>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="confirm-new-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="confirmPassword" type="password" id="confirm-new-pass" match="fields.newPassword" placeholder="Confirm Password" tabindex="3" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
</form>
Name: forms.composeForm —
<form novalidate="novalidate" name="forms.composeForm" class="v-form">
<div class="form-title">New Message</div>
<div>
<div>
<div data-testid="compose-message-provider-list">
<div class="vuetify compose-options-listing">
<div class="v-input base-select vuetify fs-block v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-19" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span class="notranslate"></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-19" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Provider</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-19" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div data-testid="compose-message-account-list">
<div class="vuetify compose-options-listing">
<div class="v-input base-select vuetify fs-block v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-23" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span class="notranslate"></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-23" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select an Account</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-23" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-testid="compose-message-reasons-list">
<div class="v-input base-select vuetify fs-block v-input--hide-details v-input--is-disabled theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-select">
<div class="v-input__control">
<div role="button" aria-haspopup="listbox" aria-expanded="false" aria-owns="list-26" class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span class="notranslate"></span></legend>
</fieldset>
<div class="v-select__slot"><label for="input-26" class="v-label v-label--is-disabled theme--light" style="left: 0px; right: auto; position: absolute;">Select a Reason</label>
<div class="v-select__selections"><input required="required" disabled="disabled" id="input-26" readonly="readonly" type="text" aria-readonly="false" autocomplete="off"></div>
<div class="v-input__append-inner">
<div class="v-input__icon v-input__icon--append"><span aria-hidden="true" class="v-icon notranslate v-icon--disabled theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true"
class="v-icon__svg">
<path d="M7,10L12,15L17,10H7Z"></path>
</svg></span></div>
</div><input type="hidden" value="[object Object]">
</div>
<div class="v-menu"><!----></div>
</div>
</div>
</div>
</div>
</div>
<div>
<div
class="v-input compose-message-textarea base-textarea vuetify fs-block v-textarea v-textarea--auto-grow v-textarea--no-resize v-input--hide-details theme--light v-text-field v-text-field--is-booted v-text-field--enclosed v-text-field--outlined v-text-field--placeholder">
<div class="v-input__control">
<div class="v-input__slot">
<fieldset aria-hidden="true">
<legend style="width: 0px;"><span class="notranslate"></span></legend>
</fieldset>
<div class="v-text-field__slot"><label for="input-29" class="v-label theme--light" style="left: 0px; right: auto; position: absolute;">Message</label><textarea name="message" required="required" maxlength="5000" id="input-29" rows="5"
style="height: 125px;"></textarea></div>
</div>
</div>
</div>
</div>
<div class="">
<div class="vuetify keep-right attachment-button"><button type="button" class="button-secondary no-capitalization base-btn vuetify v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-attach-button"><span
class="v-btn__content">Attach a file <span aria-hidden="true" class="v-icon notranslate v-icon--right theme--light"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" role="img" aria-hidden="true" class="v-icon__svg">
<path
d="M7.5,18A5.5,5.5 0 0,1 2,12.5A5.5,5.5 0 0,1 7.5,7H18A4,4 0 0,1 22,11A4,4 0 0,1 18,15H9.5A2.5,2.5 0 0,1 7,12.5A2.5,2.5 0 0,1 9.5,10H17V11.5H9.5A1,1 0 0,0 8.5,12.5A1,1 0 0,0 9.5,13.5H18A2.5,2.5 0 0,0 20.5,11A2.5,2.5 0 0,0 18,8.5H7.5A4,4 0 0,0 3.5,12.5A4,4 0 0,0 7.5,16.5H17V18H7.5Z">
</path>
</svg></span></span></button></div><input type="file" focus="0" accept=".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.txt" multiple="multiple" class="fs-block" style="display: none;">
<div data-testid="compose-message-message-attachments" class="message-attachments fs-block"></div><!---->
</div>
<div class="vuetify keep-right form-buttons"><button type="button" class="button-bigger-text base-btn vuetify v-btn v-btn--text theme--light v-size--default" data-testid="compose-message-cancel-button"><span
class="v-btn__content">Cancel</span></button><button type="button" disabled="disabled" class="button-bigger-text v-button-primary base-btn vuetify v-btn v-btn--disabled v-btn--has-bg theme--light v-size--default"
data-testid="compose-message-send-button"><span class="v-btn__content">SEND</span></button></div>
</form>
Name: forms.confirmEmailForm —
<form name="forms.confirmEmailForm" novalidate="novalidate">
<h2 class="modal-header h-style-2">Verify Email Address</h2>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="details-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input required="required" placeholder="Email Address" id="details-email" name="email" type="email" data-testid="settings-contact-form-email" class="fs-block input-with-icon"></div>
<div class="input-area-feedback">
<div class="vue-messages"><!----><!----><!----></div>
</div><span class="explanation">Is the email address listed correct? If not, please correct it above prior to clicking the "Send Email" button to update your account.</span>
</div>
</form>
Name: confirmPasswordForm —
<form name="confirmPasswordForm" novalidate="novalidate">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="current-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="password" type="password" maxlength="255" id="confirm-current-pass" placeholder="Password" class="input-with-icon fs-block"></div>
<div class="input-area-feedback">
<div class="vue-messages"><!----></div>
</div>
</div>
</form>
Name: forms.confirmPhoneForm —
<form name="forms.confirmPhoneForm" novalidate="novalidate">
<h2 class="modal-header h-style-2">Complete Account Registration</h2>
<h3 class="modal-subheader h-style-4">Please verify your mobile phone number.</h3>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" size="sm" class="iconic icon-for-input">
<path fill="#939598"
d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
</path>
</svg></span><input name="phoneNumber" type="text" required="required" placeholder="Mobile Phone" tabindex="0" maxlength="12" class="input-with-icon fs-block"></div>
<div class="input-area-feedback"><!----></div><span>
<div>You will receive a text message with a unique code to verify your mobile phone number.</div>
</span>
</div>
</form>
Name: forms.verifyCodeForm —
<form name="forms.verifyCodeForm" novalidate="novalidate" style="display: none;">
<h2 class="modal-header h-style-2">Complete Account Registration</h2>
<h3 class="modal-subheader h-style-4">Please enter the code we sent to your mobile device via SMS.</h3>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><input name="code" type="text" required="required" placeholder="Verification Code" tabindex="0" maxlength="6" autocomplete="off"></div>
<div class="input-area-feedback"><!----></div>
</div>
</form>
Name: forms.scEmailForm —
<form name="forms.scEmailForm" novalidate="novalidate"><!---->
<div class="modal-text">Please enter your email address:</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="contact-bill-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-bill-email" placeholder="Email Address" tabindex="1" maxlength="255" class="fs-block input-with-icon">
</div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="modal-text">Please enter your bill details:</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 36.5 36.5" name="bill-scode" for="contact-bill-scode" size="sm" class="iconic">
<circle fill="#08A650" cx="18.2" cy="18.3" r="18"></circle>
<path fill="#FFF" d="M23.5 17.2H11.8c0 1.8-.1 4.1-.2 6-.2 4.4 3.5 6.7 7.1 6.5 4.2-.2 5-4.7 5-4.7s-.2-4.4-.2-7.8M17.9 11.3l-5.1-.1c-.9.3-1 2-1 2V16H18l-.1-4.7zM23.5 16c0-1 0-1.8.1-2.2.2-1.9-1.4-2.4-1.4-2.4h-3c0 1.7.1 4 .1 4.7l4.2-.1z"></path>
<path fill="none" stroke="#FFF" stroke-width="1.424" stroke-miterlimit="10" d="M17.8 10.7C17.6 6 23.1 6 23.1 6"></path>
</svg><input type="text" required="required" id="contact-bill-scode" tabindex="2" name="scode" autocomplete="off" placeholder="SecureHealthCode on Bill" maxlength="11" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div autocomplete="off" class="input-area-wrapper">
<div class="input-area-field-wrapper"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 36.5 20.5" name="bill-amount" for="contact-bill-amount" size="sm" class="iconic">
<path fill="#10356B" d="M.6 20.1c-.2.1-.3-.1-.3-.2V7.5c0-.1.1-.2.2-.2C2.2 6.6 16.4 1 18.2.3h.3c1.7.7 16 6.3 17.7 7 .1 0 .2.1.2.2v12.4c0 .2-.2.3-.3.2l-17.5-6.8h-.4L.6 20.1z"></path>
</svg><input tabindex="3" type="text" id="contact-bill-amount" name="billAmount" required="required" maxlength="20" placeholder="Total Balance Due on Bill" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div><button tabindex="4" class="button-primary submit-verify">Verify</button><button type="button" tabindex="5" class="button">Back</button>
</form>
Name: forms.createForm —
<form name="forms.createForm" novalidate="novalidate">
<h2 class="modal-header">Almost there...</h2>
<div class="modal-text">Please create a password:</div>
<div class="input-area-wrapper login-password-input-area">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="contact-register-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="password" type="password" valid-password="" id="contact-register-pass" maxlength="255" placeholder="Password" tabindex="4" class="fs-block input-with-icon"></div>
<div class="input-area-rules">
<ul>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 8 characters </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 uppercase letter </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 number </li>
</ul>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="contact-register-con-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="confirmPassword" type="password" id="contact-register-con-pass" placeholder="Confirm Password" tabindex="5" class="fs-block input-with-icon"></div>
<div class="input-area-feedback">
<div class="vue-messages">
<div class="vue-message"> Please complete this field to continue. </div>
</div>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border"><input required="required" name="tou" id="contact-tou" type="checkbox" tabindex="6"><label for="contact-tou" class="create-account-terms">I agree to the
<a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
<div class="input-area-feedback">
<div class="vue-messages">
<div class="vue-message"> For legal reasons, we require all users to accept our Terms of Use. </div>
</div>
</div>
</div><button tabindex="7" class="button button-primary">Submit</button><button tabindex="8" type="button" class="button">Back</button>
</form>
Name: forms.loginForm —
<form name="forms.loginForm" novalidate="novalidate">
<h2 class="modal-header">Almost there...</h2><!---->
<div class="modal-text"> Please log in to your account: </div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="contact-login-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input tabindex="1" name="email" type="email" required="required" autocapitalize="off" maxlength="255" placeholder="Email Address" id="contact-login-email" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="contact-login-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input id="contact-login-pass" tabindex="2" name="password" type="password" required="required" placeholder="Password" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="login-forgot-password-link"><a href="" tabindex="3"> Forgot Your Password? </a></div><button tabindex="4" class="button button-primary">Submit</button><button tabindex="5" type="button" class="button">Back</button>
</form>
Name: forms.contactForm —
<form name="forms.contactForm" novalidate="novalidate">
<div class="split-input-areas-container">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="person-genderless" for="contact-zendesk-first" size="sm" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span><input required="required" name="firstName" type="text" id="contact-zendesk-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="person-genderless" for="contact-zendesk-last" size="sm" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span><input required="required" name="lastName" type="text" id="contact-zendesk-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="contact-zendesk-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="contact-zendesk-email" placeholder="Email Address" tabindex="3" maxlength="255" class="fs-block input-with-icon">
</div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border"><textarea required="required" maxlength="5000" name="message" placeholder="Start typing your message..." tabindex="4" class="fs-block"></textarea></div>
<div class="input-area-feedback"><!----></div>
</div>
<p class="info">For your security, please exclude personal health information.</p>
<div class="form-error"><!----></div><button tabindex="5" class="button-primary">Send Message</button><button tabindex="6" type="button" class="button">Back</button>
</form>
Name: forms.feedbackForm —
<form name="forms.feedbackForm" novalidate="novalidate" class="form-clean">
<div class="comment-prompt"></div><!---->
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type"><textarea placeholder="Start typing feedback..." maxlength="5000" class="fs-block"></textarea></div>
</div><button id="submit-feedback" class="button-primary send-feedback">Send Feedback</button>
</form>
Name: forms.createForm —
<form name="forms.createForm" novalidate="novalidate">
<div class="split-input-areas-container">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="person-genderless" for="register-first" size="sm" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span><input required="required" name="firstName" type="text" id="register-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="person-genderless" for="register-last" size="sm" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span><input required="required" name="lastName" type="text" id="register-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="register-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input required="required" name="email" type="email" autocapitalize="off" autocorrect="off" autosuggest="off" id="register-email" placeholder="Email Address" on-email-check-finished="asyncValidationComplete" tabindex="3"
maxlength="255" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" for="create-phone" size="sm" class="iconic icon-for-input">
<path fill="#939598"
d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
</path>
</svg></span><input name="phone" type="text" id="create-phone" phone-number="" sms-eligible="" placeholder="Mobile Phone" tabindex="4" maxlength="12" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper login-password-input-area">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="register-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="password" type="password" id="register-pass" maxlength="255" placeholder="Password" tabindex="5" class="fs-block input-with-icon"></div>
<div class="input-area-rules register">
<ul>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 8 characters </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 uppercase letter </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 number </li>
</ul>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="register-con-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="confirmPassword" type="password" id="register-con-pass" placeholder="Confirm Password" tabindex="6" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="register-checkboxes">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="receivesSms" name="receivesSms" type="checkbox" tabindex="7"><label for="receivesSms" class="create-account-terms">Text me new bills & reminders</label>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type"><input required="required" id="tou" name="tou" type="checkbox" tabindex="8"><label for="tou" class="create-account-terms">I agree to the
<a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
<div class="input-area-feedback"><!----></div>
</div>
</div><button tabindex="8" class="button button-primary register-button">Create Account</button><!----><!---->
</form>
Name: forms.loginForm —
<form name="forms.loginForm" novalidate="novalidate"><!---->
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="login-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input name="email" type="email" required="required" id="login-email" autocapitalize="off" maxlength="255" placeholder="Email Address" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="login-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input name="password" type="password" required="required" id="login-pass" placeholder="Password" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div><button class="button button-primary">Log In</button><button class="button button-secondary forgot-password">Forgot Your Password?</button>
</form>
Name: forms.forgotForm —
<form name="forms.forgotForm" novalidate="novalidate">
<div class="input-area-wrapper forgot-email-input">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16"
viewBox="0 0 16 16" name="envelope-closed" for="forgot-email" size="sm" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input name="email" type="email" required="required" maxlength="255" id="forgot-email" autocapitalize="off" on-email-check-finished="emailRegisteredCheckFinished" ng-model-options="{ updateOn: 'blur submit' }"
placeholder="Email Address" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div><button class="button button-primary"> Next </button>
</form>
Name: forms.methodForm —
<form name="forms.methodForm" novalidate="novalidate">
<div class="contact-method"><button class="button button-primary button-block u-truncate fs-block forgot-password-email" style="display: none;"> Email me (null) </button><button
class="button button-primary button-block fs-block forgot-password-phone" style="display: none;"> Text me (null) </button></div>
</form>
Name: forms.verifyForm —
<form name="forms.verifyForm" novalidate="novalidate">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper verification-code"><input name="code" type="text" all-numeric="" required="required" placeholder="Verification Code" tabindex="0" ng-model-options="{updateOn: 'default blur submit'}" maxlength="6"
autocomplete="off"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="modal-actions"><button type="button" class="button button-secondary"> I didn't receive a code </button><button class="button button-primary"> Next </button></div>
</form>
Name: forms.resetPasswordForm —
<form name="forms.resetPasswordForm" novalidate="novalidate"><!---->
<div class="input-area-wrapper login-password-input-area">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="reset-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="password" type="password" valid-password="" id="reset-pass" maxlength="255" placeholder="New Password" tabindex="2" class="fs-block input-with-icon"></div>
<div class="input-area-rules password-reset">
<ul>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 8 characters </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 uppercase letter </li>
<li class=""><span class="rule-met-icon"><svg data-icon="shape" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="shape-circle" size="sm" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0z"></path>
</svg></span> 1 number </li>
</ul>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="reset-con-pass" size="sm" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input required="required" name="confirmPassword" type="password" id="reset-con-pass" match="resetPassword.password" valid-password="" placeholder="Confirm Password" tabindex="3" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div><button tabindex="4" class="button button-primary"> Reset Password </button>
</form>
Name: forms.myChartForm —
<form name="forms.myChartForm" novalidate="novalidate">
<h2 class="modal-header h-style-2"></h2>
<div class="modal-text">The PatientWallet is where you'll be able to access all of your bills and make payments.<br><br>Let's check to see if you already have an account.</div>
<div class="input-area-wrapper solo-input">
<div class="input-area-field-wrapper"><input name="checkEmail" type="email" placeholder="Enter your email address" class="fs-block"></div>
<div class="input-area-feedback"><!----><!----></div>
</div><button id="check-for-patient-wallet-button" tabindex="8" type="submit" class="button button-primary">Search</button>
</form>
<form><!---->
<h2 class="modal-header h-style-2"> Set Up Your PatientWallet </h2><svg xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:cc="http://creativecommons.org/ns#" xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#"
xmlns:svg="http://www.w3.org/2000/svg" xmlns="http://www.w3.org/2000/svg" xmlns:sodipodi="http://sodipodi.sourceforge.net/DTD/sodipodi-0.dtd" xmlns:inkscape="http://www.inkscape.org/namespaces/inkscape" version="1.1" x="0px" y="0px"
viewBox="0 0 100 125" style="max-width: 100px; margin-bottom: -30px; fill: rgb(97, 97, 97);">
<g transform="translate(0,-952.36218)">
<path
d="m 6.0000002,973.36217 a 2.0002,2.0002 0 0 0 -2,2 l 0,54.00003 a 2.0002,2.0002 0 0 0 2,2 l 87.9999998,0 a 2.0002,2.0002 0 0 0 2,-2 l 0,-54.00003 a 2.0002,2.0002 0 0 0 -2,-2 l -87.9999998,0 z m 5.4687498,4 77.0625,0 L 50,1009.7684 11.46875,977.36217 z m -3.4687498,2.28125 25.9687498,21.84378 -25.9687498,23.375 0,-45.21878 z m 83.9999998,0 0,45.21878 -25.96875,-23.375 L 92,979.64342 z m -54.9375,24.43748 11.65625,9.8125 a 2.0002,2.0002 0 0 0 2.5625,0 l 11.65625,-9.8125 25.875,23.2813 -77.625,0 25.875,-23.2813 z"
fill-opacity="1" stroke="none" marker="none" visibility="visible" display="inline" overflow="visible" style="text-indent: 0px; text-transform: none; direction: ltr; baseline-shift: baseline; color: rgb(0, 0, 0);"></path>
</g>
</svg><br>
<div data-v-4df920db="" class="notification notification-inline failure" style="display: none;">
<div data-v-4df920db="" class="primary-icon-container u-center-vertical"><span data-v-4df920db="" class="icon-wrap"><svg data-v-4df920db="" xmlns="http://www.w3.org/2000/svg" width="28" height="28" viewBox="0 0 75.6 75.6" name="information"
class="iconic">
<path data-v-4df920db="" fill="#FFF"
d="M40.4 24c-1.4 0-2.6 1.2-2.6 2.6s1.2 2.6 2.6 2.6c1.4 0 2.6-1.2 2.6-2.6S41.8 24 40.4 24zm-3.5 6.9c-2.4 0-4.3 1.9-4.3 4.3v.9h1.7v-.9c0-1 .8-1.7 1.7-1.7s1.7.9 1.7 1.7c0 2.2-3.5 9.8-3.5 12.1 0 2.3 1.9 4.3 4.3 4.3s4.3-1.9 4.3-4.3v-.9h-1.7v.9c0 1-.8 1.7-1.7 1.7-1 0-1.7-.8-1.7-1.7 0-2 3.5-9.7 3.5-12.1s-1.9-4.3-4.3-4.3z">
</path>
<path data-v-4df920db="" fill="#FFF" d="M37.8 1.8c-19.9 0-36 16.1-36 36s16.1 36 36 36 36-16.1 36-36-16.1-36-36-36zm0 67.8C20.3 69.6 6 55.3 6 37.8S20.3 6 37.8 6s31.8 14.2 31.8 31.8c0 17.5-14.3 31.8-31.8 31.8z"></path>
</svg></span></div>
<div data-v-4df920db="" class="notification-content-container u-center-vertical">
<div data-v-4df920db="" class="notification-content"><span data-v-4df920db=""><svg data-v-4df920db="" data-icon="circle-x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="circle-x" class="iconic">
<path data-v-4df920db="" d="M8 0a8 8 0 100 16A8 8 0 008 0zM6 4.594l2 2 2-2L11.406 6l-2 2 2 2L10 11.406l-2-2-2 2L4.594 10l2-2-2-2L6 4.594z"></path>
</svg></span> There was a problem sending that code. Please try again. </div>
</div>
<div data-v-4df920db="" class="notification-close u-center-vertical"><svg data-v-4df920db="" data-icon="x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="x" size="sm"
class="iconic">
<path data-v-4df920db="" d="M3 .156L.156 3l1.438 1.406L5.188 8l-3.594 3.594L.156 13 3 15.844l1.406-1.438L8 10.812l3.594 3.594L13 15.844 15.844 13l-1.438-1.406L10.812 8l3.594-3.594L15.844 3 13 .156l-1.406 1.438L8 5.188 4.406 1.594 3 .156z">
</path>
</svg></div>
</div>
<div data-v-4df920db="" class="notification notification-inline success" style="display: none;">
<div data-v-4df920db="" class="primary-icon-container u-center-vertical"><span data-v-4df920db="" class="icon-wrap"><svg data-v-4df920db="" xmlns="http://www.w3.org/2000/svg" width="28" height="28" viewBox="0 0 75.6 75.6" name="information"
class="iconic">
<path data-v-4df920db="" fill="#FFF"
d="M40.4 24c-1.4 0-2.6 1.2-2.6 2.6s1.2 2.6 2.6 2.6c1.4 0 2.6-1.2 2.6-2.6S41.8 24 40.4 24zm-3.5 6.9c-2.4 0-4.3 1.9-4.3 4.3v.9h1.7v-.9c0-1 .8-1.7 1.7-1.7s1.7.9 1.7 1.7c0 2.2-3.5 9.8-3.5 12.1 0 2.3 1.9 4.3 4.3 4.3s4.3-1.9 4.3-4.3v-.9h-1.7v.9c0 1-.8 1.7-1.7 1.7-1 0-1.7-.8-1.7-1.7 0-2 3.5-9.7 3.5-12.1s-1.9-4.3-4.3-4.3z">
</path>
<path data-v-4df920db="" fill="#FFF" d="M37.8 1.8c-19.9 0-36 16.1-36 36s16.1 36 36 36 36-16.1 36-36-16.1-36-36-36zm0 67.8C20.3 69.6 6 55.3 6 37.8S20.3 6 37.8 6s31.8 14.2 31.8 31.8c0 17.5-14.3 31.8-31.8 31.8z"></path>
</svg></span></div>
<div data-v-4df920db="" class="notification-content-container u-center-vertical">
<div data-v-4df920db="" class="notification-content"><span data-v-4df920db=""><svg data-v-4df920db="" data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="circle-check" class="iconic">
<path data-v-4df920db="" d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> Code has been sent. </div>
</div>
<div data-v-4df920db="" class="notification-close u-center-vertical"><svg data-v-4df920db="" data-icon="x" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="x" size="sm"
class="iconic">
<path data-v-4df920db="" d="M3 .156L.156 3l1.438 1.406L5.188 8l-3.594 3.594L.156 13 3 15.844l1.406-1.438L8 10.812l3.594 3.594L13 15.844 15.844 13l-1.438-1.406L10.812 8l3.594-3.594L15.844 3 13 .156l-1.406 1.438L8 5.188 4.406 1.594 3 .156z">
</path>
</svg></div>
</div>
<div class="modal-text fs-block"></div><!---->
<div class="input-area-field-wrapper solo-input"><input name="emailVerificationCode" type="text" required="required" placeholder="Verification Code" class="fs-block"><a class="inline">Resend</a></div>
<div id="terms-of-use-input" class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="acceptTerms" name="acceptTerms" type="checkbox" tabindex="8"><label for="acceptTerms" class="create-account-terms">I agree to the
<a href="https://www.waystar.com/patientco-terms-of-use/" target="_blank">Terms of Use</a></label></div>
<div class="input-area-feedback"><!----></div>
</div><button id="verify-email-button" class="button button-primary"> Verify </button>
<div><a>Use a different email address</a></div>
</form>
Name: finishRegistrationForm —
<form name="finishRegistrationForm" novalidate="novalidate">
<div class="split-input-areas-container">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="person-genderless" for="finishRegistration-first" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span><input name="firstName" type="text" id="finishRegistration-first" placeholder="First Name" tabindex="1" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper">
<div><span class=""><svg data-icon="person" data-containertransform="scale(1 1 ) translate(0 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="person-genderless"
for="finishRegistration-last" class="iconic icon-for-input">
<path d="M8 0C5.791 0 4 2.239 4 5s1.791 5 4 5 4-2.239 4-5-1.791-5-4-5zM3.812 10c-2.1.1-3.813 1.9-3.813 4v2h16v-2c0-2.1-1.713-3.9-3.813-4-1.1 1.2-2.588 2-4.188 2-1.6 0-3.088-.8-4.188-2z"></path>
</svg></span></div><input name="lastName" type="text" id="finishRegistration-last" placeholder="Last Name" tabindex="2" class="fs-block input-with-icon">
</div>
<div class="input-area-feedback"><!----></div>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span><svg data-icon="envelope" data-containertransform="scale(1 1 ) translate(0 2 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="envelope-closed" for="finishRegistration-email" class="iconic icon-for-input">
<path d="M0 2v2l8 4 8-4V2H0zm0 4v8h16V6l-8 4-8-4z"></path>
</svg></span><input name="email" type="email" disabled="disabled" autocapitalize="off" autocorrect="off" autosuggest="off" id="finishRegistration-email" placeholder="Email Address" tabindex="3" maxlength="255"
class="fs-block input-with-icon"></div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 51 51.3" name="phone" for="finishRegistration--phone" class="iconic icon-for-input">
<path fill="#939598"
d="M1.9 13s1.1-5.3 4-8.8l3-2.2s3.4-.8 7 4.6 2.5 7.7 2.5 7.7L15.2 18s.3 3.4 1.9 5.6 8.2 9.3 10 10.7c1.8 1.3 3.3 2.1 5.2 2.1l1.3-2.3s1.1-2 3.6-1.8c2.6.3 5.7 1.2 5.7 1.2S49.5 36 49 40l-1.2 3.8s-3.6 4.3-10.7 5.3c0 0-12.7-6.5-21.5-15.6S1.9 13 1.9 13z">
</path>
</svg></span><input name="phone" type="text" id="finishRegistration-phone" placeholder="Mobile Phone" on-phone-check-finished="asyncValidationComplete" tabindex="4" maxlength="12" class="fs-block input-with-icon"></div>
<div class="input-area-feedback">
<div class="vue-messages"><!----><!----></div>
</div>
</div>
<div class="input-area-wrapper login-password-input-area">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="finishRegistration-pass" class="iconic icon-for-input">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input name="password" type="password" id="finishRegistration-pass" maxlength="255" placeholder="Password" tabindex="5" class="fs-block input-with-icon"></div>
<div class="input-area-rules">
<ul>
<li class="min-char-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 8 characters </li>
<li class="upper-case-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 1 uppercase letter </li>
<li class="digit-rule"><span class="rule-met-icon"><svg data-icon="circle-check" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16" name="circle-check" class="iconic">
<path d="M8 0a8 8 0 100 16A8 8 0 008 0zm3 4.594L12.406 6 7 11.406 3.594 8 5 6.594l2 2 4-4z"></path>
</svg></span> 1 number </li>
</ul>
</div>
</div>
<div class="input-area-wrapper">
<div class="input-area-field-wrapper"><span class=""><svg data-icon="lock" data-containertransform="scale(1 1 ) translate(2 1 )" data-width="null" data-height="null" xmlns="http://www.w3.org/2000/svg" width="16" height="16" viewBox="0 0 16 16"
name="lock-locked" for="finishRegistration-con-pass" class="iconic">
<path d="M8 1C5.79 1 4 2.79 4 5v2H2v8h12V7h-2V5c0-2.21-1.79-4-4-4zm0 2c1.19 0 2 .81 2 2v2H6V5c0-1.19.81-2 2-2z"></path>
</svg></span><input name="confirmPassword" type="password" id="finishRegistration-con-pass" match="" placeholder="Confirm Password" tabindex="6" class="fs-block input-with-icon"></div>
<div class="input-area-feedback"><!----></div>
</div>
<div class="register-checkboxes">
<div class="input-area-wrapper">
<div class="input-area-field-wrapper no-initial-border inline-input-type"><input id="finishRegistration-receivesSms" name="receivesSms" type="checkbox" tabindex="7"><label for="finishRegistration-receivesSms" class="create-account-terms">Text
me new bills & reminders</label></div>
</div>
</div><button tabindex="8" class="button button-primary"> Save </button>
</form>
Name: forms.verifyEmailCodeForm —
<form data-v-6667e338="" name="forms.verifyEmailCodeForm" novalidate="novalidate">
<div data-v-6667e338="" class="interaction-feedback vue-messages"><!----></div>
<div data-v-6667e338="" class="input-area-wrapper">
<div data-v-6667e338="" class="input-area-field-wrapper"><input data-v-6667e338="" name="emailVerificationCode" type="text" inputmode="decimal" required="required" placeholder="Verification Code" tabindex="0" maxlength="6"
class="email-verification-code"><a data-v-6667e338="" class="inline resend-code">Resend</a></div>
<div data-v-6667e338="" class="input-area-feedback">
<div data-v-6667e338="" class="vue-messages">
<div data-v-6667e338="" class="vue-message" style="display: none;"> Please complete this field to continue. </div>
</div>
</div>
</div>
</form>
Text Content
We're sorry but PatientWallet doesn't work properly without JavaScript enabled. Please enable it to continue. Patientco Logo PATIENTCO Patientco Enter the unique details from your bill. We cannot find a bill matching the SecureHealthCode and total balance you've entered. Please check to make sure your details are correct. You have attempted to find a bill too many times. For security reasons, your ability to search for bills has been disabled for a few minutes. Find Bill Need help? Cambiar a Español Log In Contact Us Welcome to the PatientWallet®! We’ve partnered with your healthcare provider to give you the simplest, most secure payment experience possible. © 2023 About Privacy Terms WHO WOULD YOU LIKE TO VERIFY? Note: If you're adding accounts for an infant, use the guarantor's SSN BROWSER INFO * Browser: * Version: * User Agent: Loading IP Details... * IP: * Location: , , APPLICATION INFO * Root URL: https://www.gopatientco.com/ * Base URL: * API URL: /api * Backendless: false * Environment: production * Languages: [ "en", "es" ] * Pendo Enabled: false * Version: Copy to Clipboard CHANGE PASSWORD * 8 characters * 1 uppercase letter * 1 number Save Changes INPUT MESSAGE New Message Select a Provider Select an Account Select a Reason Message Attach a file CancelSEND {{name}} does not support messaging through Patientco. If you would like to contact your provider, please call {{billingPhoneNumber}}. We apologize for any inconvenience. There was a problem sending that email. Please try again. VERIFY EMAIL ADDRESS Is the email address listed correct? If not, please correct it above prior to clicking the "Send Email" button to update your account. Send Email Submit There was a problem sending that code. Please try again. That code was invalid or expired. Please try again. COMPLETE ACCOUNT REGISTRATION PLEASE VERIFY YOUR MOBILE PHONE NUMBER. You will receive a text message with a unique code to verify your mobile phone number. COMPLETE ACCOUNT REGISTRATION PLEASE ENTER THE CODE WE SENT TO YOUR MOBILE DEVICE VIA SMS. By verifying your phone number, you agree to allow Patientco to send you periodic text messages on behalf of your provider for any account-related activity. Patientco may use an automated system to send you electronic communications including text, phone, or email. Patientco does not have a separate charge for this service; however, subject to the terms and conditions of your mobile carrier, message and data rates may apply. By providing your consent to participate in this program, you approve any such charges from your mobile carrier. You may opt out of this program at any time by emailing Patientco at support@patientco.com. Learn MoreI didn't receive a code Send Code I NEED HELP WITH: Understanding my bill I need an itemized bill I lost my Patientco bill Logging in Reset my password I HAVE A QUESTION ABOUT: A charge on my bill Creating a payment plan A duplicate charge or bill Missing payments Updating Information Insurance Requesting an itemized bill Financial assistance Estimate Other Back LET'S GET YOU TO THE RIGHT PLACE. Please enter your email address: Please enter your bill details: VerifyBack ALMOST THERE... Please create a password: * 8 characters * 1 uppercase letter * 1 number Please complete this field to continue. I agree to the Terms of Use For legal reasons, we require all users to accept our Terms of Use. SubmitBack ALMOST THERE... Please log in to your account: Forgot Your Password? SubmitBack THANKS FOR REACHING OUT! WE'RE EXCITED TO HEAR FROM YOU. For your security, please exclude personal health information. Send MessageBack 0 1 2 3 4 5 6 7 8 9 10 Not at all likely Extremely likely Send Feedback There was a problem sending that code. Please try again. That code was invalid or expired. Please try again. WELCOME TO YOUR PATIENTWALLET® Create AccountLog In * 8 characters * 1 uppercase letter * 1 number Text me new bills & reminders I agree to the Terms of Use Create Account Log InForgot Your Password? FORGOT YOUR PASSWORD? WE'VE GOT YOU COVERED. Next HOW WOULD YOU LIKE TO RESET YOUR PASSWORD? Email me (null) Text me (null) PLEASE ENTER YOUR VERIFICATION CODE. I didn't receive a code Next CHECK YOUR EMAIL AND CLICK THE LINK. We just sent an email containing a password reset link to null. If you don't see it in your inbox, be sure to check your spam folder. Try Again CREATE YOUR NEW PASSWORD. * 8 characters * 1 uppercase letter * 1 number Reset Password WELCOME TO YOUR PATIENTWALLET® Log In with null The PatientWallet is where you'll be able to access all of your bills and make payments. Let's check to see if you already have an account. Search SET UP YOUR PATIENTWALLET There was a problem sending that code. Please try again. Code has been sent. Resend I agree to the Terms of Use Verify Use a different email address WELCOME BACK! It looks like you've accessed your PatientWallet before through MyChart. Please finish setting up your account by adding your phone number and a password. * 8 characters * 1 uppercase letter * 1 number Text me new bills & reminders Save WHICH BILL WOULD YOU LIKE TO PAY? Pay New Bill ENTER DETAILS FROM YOUR NEW BILL. We cannot find a bill matching the SecureHealthCode and total balance you've entered. Please check to make sure your details are correct. You have attempted to find a bill too many times. For security reasons, your ability to search for bills has been disabled for a few minutes. Find Bill Loading... NOTIFICATIONS No Notifications You are now being redirected to your PatientWallet® An error occurred while attempting to redirect you to your PatientWallet®. Please try again, and if you continue to have problems please contact your provider. UPDATES TO TERMS OF USE & PRIVACY POLICY We have updated our Terms of Use and Privacy Policy to make it easier for you to understand what information we collect and why. As a friendly reminder, Patientco will never share your information with third party marketers, and you can always update your Communication Preferences within your Settings. We encourage you to review our new Terms of Use and Privacy Policy. To accept the new Terms of Use and Privacy Policy, click "Accept" below. Accept VERIFY EMAIL We were unable to send the verification email. Please try again. Code has been sent. Explanation Resend Please complete this field to continue. Verify