{"id":585,"date":"2018-03-28T13:10:45","date_gmt":"2018-03-28T13:10:45","guid":{"rendered":"https:\/\/medlogix.com\/forms\/medical-records-review\/"},"modified":"2022-11-08T16:23:11","modified_gmt":"2022-11-08T21:23:11","slug":"medical-records-review","status":"publish","type":"page","link":"https:\/\/medlogix.com\/medical-records-review\/","title":{"rendered":"Medical Records Review"},"content":{"rendered":"\n<h1>\n\t\tMEDICAL RECORDS REVIEW\n\t<\/h1>\n\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' ><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/585' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_4_77\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_77\" ><h3 class=\"gsection_title\">Referral Party Information<\/h3><\/div><div id=\"field_4_88\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_88\" ><label class='gfield_label gform-field-label' for='input_4_88'>Referring Source (Adjuster Name)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_4_88' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_2\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_2\" ><label class='gfield_label gform-field-label' for='input_4_2'>Referring Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_4_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_89\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_89\" ><label class='gfield_label gform-field-label' for='input_4_89'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_4_89' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_22\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_22\" ><label class='gfield_label gform-field-label' for='input_4_22'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_4_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_24\" ><label class='gfield_label gform-field-label' for='input_4_24'>Zip<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_25\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_25\" ><label class='gfield_label gform-field-label' for='input_4_25'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_4_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_26\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_26\" ><label class='gfield_label gform-field-label' for='input_4_26'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_4_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_90\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_90\" ><label class='gfield_label gform-field-label' for='input_4_90'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_90' id='input_4_90' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_91\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_91\" ><h3 class=\"gsection_title\">Bill To Information<\/h3><\/div><div id=\"field_4_92\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_92\" ><label class='gfield_label gform-field-label' for='input_4_92'>Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_4_92' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_93\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_93\" ><label class='gfield_label gform-field-label' for='input_4_93'>Referring Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_4_93' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_94\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_94\" ><label class='gfield_label gform-field-label' for='input_4_94'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_4_94' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_95\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_95\" ><label class='gfield_label gform-field-label' for='input_4_95'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_96\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_96\" ><label class='gfield_label gform-field-label' for='input_4_96'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_4_96' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_97\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_97\" ><label class='gfield_label gform-field-label' for='input_4_97'>Zip<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_4_97' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_98\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_98\" ><label class='gfield_label gform-field-label' for='input_4_98'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_4_98' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_99\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_99\" ><label class='gfield_label gform-field-label' for='input_4_99'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_4_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_100\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_100\" ><label class='gfield_label gform-field-label' for='input_4_100'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_100' id='input_4_100' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_101\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_101\" ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><div id=\"field_4_102\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_102\" ><label class='gfield_label gform-field-label' for='input_4_102'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_4_102' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_103\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_103\" ><label class='gfield_label gform-field-label' for='input_4_103'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_4_103' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_104\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_104\" ><label class='gfield_label gform-field-label' for='input_4_104'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_4_104' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_105\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_105\" ><label class='gfield_label gform-field-label' for='input_4_105'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_4_105' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_106\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_106\" ><label class='gfield_label gform-field-label' for='input_4_106'>Zip<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_4_106' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_107\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_107\" ><label class='gfield_label gform-field-label' for='input_4_107'>Home Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_4_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_108\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_108\" ><label class='gfield_label gform-field-label' for='input_4_108'>Work Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_4_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_109\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_109\" ><label class='gfield_label gform-field-label' for='input_4_109'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_4_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_110\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_110\" ><label class='gfield_label gform-field-label' for='input_4_110'>Social Security<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_4_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_113\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_113\" ><label class='gfield_label gform-field-label' for='input_4_113'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_113' id='input_4_113' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_113_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_113_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_113' class='gform_hidden' value='https:\/\/medlogix.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_111\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_111\" ><label class='gfield_label gform-field-label' for='input_4_111'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_4_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_114\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_114\" ><label class='gfield_label gform-field-label' for='input_4_114'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_4_114' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_115\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_115\" ><label class='gfield_label gform-field-label' for='input_4_115'>Claim Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_4_115' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_116\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_116\" ><label class='gfield_label gform-field-label' for='input_4_116'>Date of Injury \/ Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_116' id='input_4_116' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_116_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_116_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_116' class='gform_hidden' value='https:\/\/medlogix.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_117\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_117\" ><label class='gfield_label gform-field-label' for='input_4_117'>Injury Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_117' id='input_4_117' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_118\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_118\" ><label class='gfield_label gform-field-label' for='input_4_118'>Other Complaints<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_118' id='input_4_118' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_119\" ><legend class='gfield_label gform-field-label' >Currently Working?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_119'>\n\t\t\t<div class='gchoice gchoice_4_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Yes'  id='choice_4_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_119_0' id='label_4_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='No'  id='choice_4_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_119_1' id='label_4_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_120\" ><legend class='gfield_label gform-field-label' >Claim Accepted?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_120'>\n\t\t\t<div class='gchoice gchoice_4_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='Yes'  id='choice_4_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_120_0' id='label_4_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='No'  id='choice_4_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_120_1' id='label_4_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_121\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_121\" ><label class='gfield_label gform-field-label' for='input_4_121'>Jurisdiction State<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_4_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_122\" class=\"gfield gfield--type-select gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_122\" ><label class='gfield_label gform-field-label' for='input_4_122'>Type of Claim<\/label><div class='ginput_container ginput_container_select'><select name='input_122' id='input_4_122' class='large gfield_select'     aria-invalid=\"false\" ><option value='Automobile' >Automobile<\/option><option value='General Liability' >General Liability<\/option><option value='Short Term Disability' >Short Term Disability<\/option><option value='Long Term Disability' >Long Term Disability<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_4_123\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_123\" ><h3 class=\"gsection_title\">Patient Attorney Information<\/h3><\/div><fieldset id=\"field_4_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_124\" ><legend class='gfield_label gform-field-label' >Is the patient represented?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_124'>\n\t\t\t<div class='gchoice gchoice_4_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Yes'  id='choice_4_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_124_0' id='label_4_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='No'  id='choice_4_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_124_1' id='label_4_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_125\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_125\" ><label class='gfield_label gform-field-label' for='input_4_125'>Attorney Name<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_4_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_126\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_126\" ><label class='gfield_label gform-field-label' for='input_4_126'>Firm Name<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_4_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_127\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_127\" ><label class='gfield_label gform-field-label' for='input_4_127'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_4_127' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_128\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_128\" ><label class='gfield_label gform-field-label' for='input_4_128'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_4_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_129\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_129\" ><label class='gfield_label gform-field-label' for='input_4_129'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_4_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_130\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_130\" ><label class='gfield_label gform-field-label' for='input_4_130'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_4_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_131\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_131\" ><label class='gfield_label gform-field-label' for='input_4_131'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_4_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_132\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_132\" ><label class='gfield_label gform-field-label' for='input_4_132'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_4_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_133\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_133\" ><h3 class=\"gsection_title\">Defense Attorney Information<\/h3><\/div><fieldset id=\"field_4_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_134\" ><legend class='gfield_label gform-field-label' >Is the defense attorney assigned?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_134'>\n\t\t\t<div class='gchoice gchoice_4_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Yes'  id='choice_4_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_134_0' id='label_4_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_4_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_134_1' id='label_4_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_135\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_135\" ><label class='gfield_label gform-field-label' for='input_4_135'>Attorney Name<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_4_135' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_136\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_136\" ><label class='gfield_label gform-field-label' for='input_4_136'>Firm Name<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_4_136' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_137\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_137\" ><label class='gfield_label gform-field-label' for='input_4_137'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_4_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_138\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_138\" ><label class='gfield_label gform-field-label' for='input_4_138'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_4_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_139\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_139\" ><label class='gfield_label gform-field-label' for='input_4_139'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_4_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_140\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_140\" ><label class='gfield_label gform-field-label' for='input_4_140'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_4_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_141\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_141\" ><label class='gfield_label gform-field-label' for='input_4_141'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_4_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_142\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_142\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_143\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_143\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Issues to be Addressed<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_143'><div class='gchoice gchoice_4_143_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.1' type='checkbox'  value='Separate cover letter to follow'  id='choice_4_143_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_1' id='label_4_143_1' class='gform-field-label gform-field-label--type-inline'>Separate cover letter to follow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.2' type='checkbox'  value='History of injury and subsequent treatment'  id='choice_4_143_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_2' id='label_4_143_2' class='gform-field-label gform-field-label--type-inline'>History of injury and subsequent treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.3' type='checkbox'  value='Prior injuries and\/or pre-existing conditions'  id='choice_4_143_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_3' id='label_4_143_3' class='gform-field-label gform-field-label--type-inline'>Prior injuries and\/or pre-existing conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.4' type='checkbox'  value='Present status'  id='choice_4_143_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_4' id='label_4_143_4' class='gform-field-label gform-field-label--type-inline'>Present status<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.5' type='checkbox'  value='Comprehensive physical exam including non-physiologic findings'  id='choice_4_143_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_5' id='label_4_143_5' class='gform-field-label gform-field-label--type-inline'>Comprehensive physical exam including non-physiologic findings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.6' type='checkbox'  value='Whether objective findings support the subjective complaints'  id='choice_4_143_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_6' id='label_4_143_6' class='gform-field-label gform-field-label--type-inline'>Whether objective findings support the subjective complaints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.7' type='checkbox'  value='Diagnosis \/ Prognosis'  id='choice_4_143_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_7' id='label_4_143_7' class='gform-field-label gform-field-label--type-inline'>Diagnosis \/ Prognosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.8' type='checkbox'  value='Can claimant return to work at this time with no restrictions?'  id='choice_4_143_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_8' id='label_4_143_8' class='gform-field-label gform-field-label--type-inline'>Can claimant return to work at this time with no restrictions?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.9' type='checkbox'  value='What are claimant&#039;s physical capabilities?'  id='choice_4_143_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_9' id='label_4_143_9' class='gform-field-label gform-field-label--type-inline'>What are claimant's physical capabilities?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.11' type='checkbox'  value='Is claimant at Maximum Medical Improvement?'  id='choice_4_143_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_11' id='label_4_143_11' class='gform-field-label gform-field-label--type-inline'>Is claimant at Maximum Medical Improvement?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.12' type='checkbox'  value='Is there any permanency of injuries or residuals?'  id='choice_4_143_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_12' id='label_4_143_12' class='gform-field-label gform-field-label--type-inline'>Is there any permanency of injuries or residuals?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.13' type='checkbox'  value='Is current treatment reasonable and necessary?'  id='choice_4_143_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_13' id='label_4_143_13' class='gform-field-label gform-field-label--type-inline'>Is current treatment reasonable and necessary?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.14' type='checkbox'  value='Is further treatment needed? If so, what kind, for what length of time and at what frequency?'  id='choice_4_143_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_14' id='label_4_143_14' class='gform-field-label gform-field-label--type-inline'>Is further treatment needed? If so, what kind, for what length of time and at what frequency?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_143_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.15' type='checkbox'  value='Other'  id='choice_4_143_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_143_15' id='label_4_143_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_144\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_144\" ><h3 class=\"gsection_title\">Appointment Information<\/h3><\/div><div id=\"field_4_148\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_148\" ><label class='gfield_label gform-field-label' for='input_4_148'>Specialty<\/label><div class='ginput_container ginput_container_select'><select name='input_148' id='input_4_148' class='large gfield_select'     aria-invalid=\"false\" ><option value='Allergy' >Allergy<\/option><option value='Anesthesiology' >Anesthesiology<\/option><option value='Chiropractic' >Chiropractic<\/option><option value='Critical Care\/Trauma' >Critical Care\/Trauma<\/option><option value='Dentistry' >Dentistry<\/option><option value='Ear, Nose, Throat' >Ear, Nose, Throat<\/option><option value='Endocrinology' >Endocrinology<\/option><option value='Family Practice' >Family Practice<\/option><option value='Gastro Intestinal' >Gastro Intestinal<\/option><option value='General Surgery' >General Surgery<\/option><option value='Hematology' >Hematology<\/option><option value='Internal Medicine' >Internal Medicine<\/option><option value='Neurology' >Neurology<\/option><option value='Neuropsychology' >Neuropsychology<\/option><option value='Neurosurgery' >Neurosurgery<\/option><option value='Occupational Medicine' >Occupational Medicine<\/option><option value='Occupational Therapy' >Occupational Therapy<\/option><option value='Oral Surgery' >Oral Surgery<\/option><option value='Orthopedic Surgery' >Orthopedic Surgery<\/option><option value='Other' >Other<\/option><option value='Pain Management' >Pain Management<\/option><option value='Physiatry' >Physiatry<\/option><option value='Physical Therapy' >Physical Therapy<\/option><option value='Plastic Surgery' >Plastic Surgery<\/option><option value='Psychiatry' >Psychiatry<\/option><option value='Psychology' >Psychology<\/option><option value='Vascular Surgery' >Vascular Surgery<\/option><\/select><\/div><\/div><div id=\"field_4_147\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_147\" ><label class='gfield_label gform-field-label' for='input_4_147'>Specialty (Other)<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_4_147' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_192\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_192\" ><label class='gfield_label gform-field-label' for='input_4_192'>Requested Examiner&#039;s Name (Optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_4_192' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_193\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_193\" ><label class='gfield_label gform-field-label' for='input_4_193'>Time Frame for Appointment<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_194\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_194\" ><label class='gfield_label gform-field-label' for='input_4_194'>Time Frame for Report<\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_4_194' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_191\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_191\" ><h3 class=\"gsection_title\">Treating Physicians<\/h3><\/div><div id=\"field_4_145\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_145\" ><label class='gfield_label gform-field-label' for='input_4_145'>Provider Under Review (Name)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_4_145' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_149\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_149\" ><label class='gfield_label gform-field-label' for='input_4_149'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_4_149' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_150\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_150\" ><label class='gfield_label gform-field-label' for='input_4_150'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_4_150' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_151\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_151\" ><label class='gfield_label gform-field-label' for='input_4_151'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_4_151' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_152\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_152\" ><label class='gfield_label gform-field-label' for='input_4_152'>Zip<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_4_152' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_154\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_154\" ><label class='gfield_label gform-field-label' for='input_4_154'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_4_154' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_155\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_155\" ><label class='gfield_label gform-field-label' for='input_4_155'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_4_155' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_156\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_156\" ><label class='gfield_label gform-field-label' for='input_4_156'>Email<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_4_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_157\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_157\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_158\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_158\" ><label class='gfield_label gform-field-label' for='input_4_158'>Secondary Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_4_158' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_159\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_159\" ><label class='gfield_label gform-field-label' for='input_4_159'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_4_159' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_160\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_160\" ><label class='gfield_label gform-field-label' for='input_4_160'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_4_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_161\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_161\" ><label class='gfield_label gform-field-label' for='input_4_161'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_4_161' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_162\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_162\" ><label class='gfield_label gform-field-label' for='input_4_162'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_4_162' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_163\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_163\" ><label class='gfield_label gform-field-label' for='input_4_163'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_4_163' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_164\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_164\" ><label class='gfield_label gform-field-label' for='input_4_164'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_4_164' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_165\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_165\" ><label class='gfield_label gform-field-label' for='input_4_165'>Email<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_4_165' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_170\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_170\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_166\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_166\" ><label class='gfield_label gform-field-label' for='input_4_166'>Secondary Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_4_166' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_167\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_167\" ><label class='gfield_label gform-field-label' for='input_4_167'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_4_167' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_168\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_168\" ><label class='gfield_label gform-field-label' for='input_4_168'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_4_168' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_169\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_169\" ><label class='gfield_label gform-field-label' for='input_4_169'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_4_169' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_171\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_171\" ><label class='gfield_label gform-field-label' for='input_4_171'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_4_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_172\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_172\" ><label class='gfield_label gform-field-label' for='input_4_172'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_4_172' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_173\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_173\" ><label class='gfield_label gform-field-label' for='input_4_173'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_4_173' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_174\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_174\" ><label class='gfield_label gform-field-label' for='input_4_174'>Email<\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_4_174' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_175\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_175\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_176\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_176\" ><label class='gfield_label gform-field-label' for='input_4_176'>Secondary Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_4_176' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_177\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_177\" ><label class='gfield_label gform-field-label' for='input_4_177'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_4_177' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_178\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_178\" ><label class='gfield_label gform-field-label' for='input_4_178'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_4_178' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_179\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_179\" ><label class='gfield_label gform-field-label' for='input_4_179'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_4_179' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_180\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_180\" ><label class='gfield_label gform-field-label' for='input_4_180'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_4_180' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_181\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_181\" ><label class='gfield_label gform-field-label' for='input_4_181'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_4_181' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_182\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_182\" ><label class='gfield_label gform-field-label' for='input_4_182'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_4_182' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_183\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_183\" ><label class='gfield_label gform-field-label' for='input_4_183'>Email<\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_4_183' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_184\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_184\" ><h3 class=\"gsection_title\">Medical Records<\/h3><\/div><fieldset id=\"field_4_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_185\" ><legend class='gfield_label gform-field-label' >Are the records available?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_185'>\n\t\t\t<div class='gchoice gchoice_4_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Yes'  id='choice_4_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_185_0' id='label_4_185_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='No'  id='choice_4_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_185_1' id='label_4_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_186\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_186\" ><label class='gfield_label gform-field-label' for='input_4_186'>Delivery Method<\/label><div class='ginput_container ginput_container_select'><select name='input_186' id='input_4_186' class='large gfield_select'     aria-invalid=\"false\" ><option value='Mail' >Mail<\/option><option value='Email' >Email<\/option><option value='Fax' >Fax<\/option><option value='CSG Pickup' >CSG Pickup<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_4_187\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_187\" ><label class='gfield_label gform-field-label' for='input_4_187'>Other Delivery Method<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_4_187' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_188\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_188\" ><h3 class=\"gsection_title\"><\/h3><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_4\"]){return false;}  if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  jQuery(\"#gform_4\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            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