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1 forms found in the DOM

POST /MCH/accesscheck.asp

<form autocomplete="off" method="post" action="/MCH/accesscheck.asp" id="accessForm" onsubmit="return doAccessCheck(1,1,'/MCH/en-US/Images/warning.png',0,0,'accessErrorMessage','accessForm',9);">
  <div class="formcontents">
    <div class="hidden"><input type="hidden" class="hidden" name="accessformtoken" value="F6CA536D125A491BA6754635330D5AEB" autocomplete="off"></div>
    <script type="text/javascript">
      var sEmptyFieldErrorAccess = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your activation code."),
        sInvalidFieldErrorAccess = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid activation code.");
    </script>
    <fieldset class="formsection">
      <legend class="compact header small">MyCenturaHealth activation code</legend>
      <p class="helptext">Enter your activation code as it appears on your enrollment letter or After Visit Summary®. Your code is not case sensitive.</p><label class="clearlabel inlinelabel" for="code1">Activation Code Part 1</label>
      <div class="segment5"><input class="jsreq" type="text" name="code" id="code1" maxlength="5" value="4VR8V" onblur="isDiscreteFieldsError('code','2','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'',this,'1','');"
          onkeyup="autotab(event,this,document.getElementById('code2'));isDiscreteFieldsError('code','2','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'1',this,'1','');"
          onkeydown="checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'code',1);" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'-','1');" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div><span class="separator">-</span><label class="clearlabel inlinelabel" for="code2">Activation Code Part 2</label>
      <div class="segment5"><input class="jsreq" type="text" name="code" id="code2" maxlength="5" value="R3BKD" onblur="isDiscreteFieldsError('code','2','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'',this,'1','');"
          onkeyup="isDiscreteFieldsError('code','2','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'1',this,'1','');" onkeydown="checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'code',2);"
          onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'-','1');" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div>
      <div id="codeerror" class="alert signUpFieldError" aria-live="polite"></div>
    </fieldset>
    <div class="formsection"><label for="ssn4" class="header small compact">Social Security number (last 4 digits)</label>
      <p class="helptext">Please enter the last 4 digits of your Social Security number. <strong>
          <font color="#FF0000">If you have not provided Centura Health with this information, enter "9999”</font>
        </strong></p>
      <script type="text/javascript">
        var sEmptyFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter the last 4 digits of your Social Security number.");
        var sInvalidFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid last 4 digits of Social Security number.");
      </script>
      <div class="segment4"><input class="jsreq" type="password" name="ssn4" id="ssn4" value="" maxlength="4" onkeyup="isBasicInlineValidationError(this,'ssn4error',sEmptyFieldErrorssn4,'1','1','','','','1','',-1);"
          onblur="isBasicInlineValidationError(this,'ssn4error',sEmptyFieldErrorssn4,'1','','','',sInvalidFieldErrorssn4,'','',-1);" autocomplete="off">
        <div class="helptext accessibleLabel">nnnn</div>
      </div>
      <div id="ssn4error" class="alert signUpFieldError" aria-live="polite"></div>
    </div>
    <script type="text/javascript">
      var sEmptyFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your date of birth."),
        sInvalidFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid date of birth.");
    </script>
    <fieldset class="formsection">
      <legend class="compact header small">Date of birth</legend>
      <p class="helptext">Enter your date of birth in the format shown, using 4 digits for the year.</p><label class="clearlabel inlinelabel" for="dob1">Month of birth</label>
      <div class="segment2"><input class="jsreq" type="text" name="dob" id="dob1" maxlength="2" value=""
          onkeyup="autotab(event,this,document.getElementById('dob2')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',1);"
          onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">mm</div>
      </div><span class="separator subtle">/</span><label class="clearlabel inlinelabel" for="dob2">Day of birth</label>
      <div class="segment2"><input class="jsreq" type="text" name="dob" id="dob2" maxlength="2" value=""
          onkeyup="autotab(event,this,document.getElementById('dob3')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',2);"
          onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">dd</div>
      </div><span class="separator subtle">/</span><label class="clearlabel inlinelabel" for="dob3">Year of birth</label>
      <div class="segment4"><input class="jsreq" type="text" name="dob" id="dob3" maxlength="4" value="" onkeyup="isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,1,1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',3);"
          onblur="easyDOBEntry(this,1,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">yyyy</div>
      </div>
      <div id="doberror" class="alert signUpFieldError" aria-live="polite"></div>
    </fieldset>
    <div class="formsection formbuttons"><input class="hidden" type="hidden" id="jsenabled" name="jsenabled" value="0" autocomplete="off"><input class="hidden" type="hidden" name="nfrmhypsp" value="1" autocomplete="off"><input class="hidden"
        type="hidden" name="access" value="Next" autocomplete="off"><input class="button jsreq nextstep" type="submit" name="access" id="access" value="Next" title="" autocomplete="off"></div>
  </div>
</form>

Text Content

PLEASE IDENTIFY YOURSELF





All fields are required.


MyCenturaHealth activation code

Enter your activation code as it appears on your enrollment letter or After
Visit Summary®. Your code is not case sensitive.

Activation Code Part 1
xxxxx
-Activation Code Part 2
xxxxx

Social Security number (last 4 digits)

Please enter the last 4 digits of your Social Security number. If you have not
provided Centura Health with this information, enter "9999”

nnnn

Date of birth

Enter your date of birth in the format shown, using 4 digits for the year.

Month of birth
mm
/Day of birth
dd
/Year of birth
yyyy


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