Lotus Forms Samples (Medical Eligibility Form)

Rating:	unrated
Popularity:
Accesses:	35
NavCode®:	1WP1001YK
Creation date:	7/15/09
Updated date:	7/15/09
Provider:	IBM

Close [x]

Support Information

This portlet is supported by IBM through the normal Software Support channels. To report a problem with this sample, entitled Customers should call 1-800-IBM-SERV to report a problem with this Lotus Form Sample.

Close [x]

Contact the Provider

Item Details that you are requesting information for:-

Name

NavCode

Provider

The fields indicated with an asterisk (*) are required to complete this transaction; other fields are optional.

Salutation

First name *

Last name *

E-mail address *

Phone

Position or title

Company

(Enter full company name, not abbreviations.)

Address

City

State/Province

Zip/Postal code

Country *

Message *

In order to fulfill your request for further information, the information you provide in this form will be forwarded to the IBM Business Partner. Thank you for your interest.

By clicking "Submit" you agree that IBM may process your data in the manner indicated above and as described in Privacy.

Description:

Online form completed by the healthcare provider verifying the need for medical treatment/coverage for a specific condition.

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.
Dynamic Sections - Based on user input, these become visible to request additional information from the user.
Attachments - The user can attach files to the form and view attachments.

To review this item please login.

No reviews at this time.

Show all | Hide all

This sample requires IBM Lotus Viewer 3.5, Web Forms Server 3.5 or higher.

English

Worldwide

Healthcare

Free

Software
- IBM Lotus products
  - IBM Lotus Forms
- Operating system

English

Small & medium business

IBM Lotus Forms

Straight-through processing

Supported

IBM Developed: This item works with the respective IBM products and services offerings.

Learn about the levels of validation.

IBM

IBM is the world's largest information technology company, with 80 years of leadership in helping businesses innovate. IBM Software offers the widest range of applications, middleware and operating systems for all types of computing platforms, allowing customers to take full advantage of the new era of e-business.

The fastest way to get more information about IBM software is through the IBM Software home.

What do you want to do?

Related Catalogs

Lotus Forms