Description:
Online form a health plan member completes to confirm/request coverage for a medical expense.
This form includes the following features:
- Wizard Pages - Longer forms are separated into multiple pages for ease of use. Page navigation guides the user from one section to the next.
- Date Selector - The user can type a date in the entry field or select a date by clicking the calendar icon. In this form, the user can change the year by clicking on it.
- Data Instance based on CDA standard.
- Age calculator - Calculates the user's age based on user input.
- Dynamic Sections - Based on user input, these become visible to request additional information from the user.
- Other health plan information - Appears if the user indicates another health plan is available.
- Patient details - Fields switch between active and inactive based on user response.
- Additional details - Appear if the user needs to add additional details.
- Data Validation - These fields check to insure user entered information is valid.
- From / To - Ensures the date in the "From" field is earlier than the date in the "To" field.
- ZIP code format - Ensures the ZIP code fits the required format and number of characters.
- NPI# format - Ensures the NPI# format fits the required format and number of characters.
- Table - An expandable list of items organized into rows. The user can add rows to the table to insert additional information.
- Calculator - A mathematical compute that calculates the total of user entered data. When the user adds "Charges", the "Total Charges" and "Amount Due" will display totals.
- Click-Wrap Signature button - The user's digital signature using Click-Wrap signing technology.
Support information
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