{"id":586,"date":"2018-03-28T13:10:53","date_gmt":"2018-03-28T13:10:53","guid":{"rendered":"https:\/\/medlogix.com\/forms\/field-case-management\/"},"modified":"2022-11-08T16:24:22","modified_gmt":"2022-11-08T21:24:22","slug":"field-case-management","status":"publish","type":"page","link":"https:\/\/medlogix.com\/field-case-management\/","title":{"rendered":"Field Case Management"},"content":{"rendered":"\n<h1>\n\t\tFIELD CASE MANAGEMENT\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_5' ><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/586' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_5_1\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><h3 class=\"gsection_title\">Service Information<\/h3><\/div><div id=\"field_5_2\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\" ><label class='gfield_label gform-field-label' for='input_5_2'>Service Request<\/label><div class='ginput_container ginput_container_select'><select name='input_2' id='input_5_2' class='large gfield_select'     aria-invalid=\"false\" ><option value='New File' >New File<\/option><option value='Reopen File' >Reopen File<\/option><option value='Initial Evaluation' >Initial Evaluation<\/option><option value='Field Case Management' >Field Case Management<\/option><option value='Telephonic Case Management' >Telephonic Case Management<\/option><option value='One Task Management' >One Task Management<\/option><option value='Initial\/One-Shot Assignemnt' >Initial\/One-Shot Assignemnt<\/option><option value='Cost Projection' >Cost Projection<\/option><option value='Lifetime Cost Projection' >Lifetime Cost Projection<\/option><\/select><\/div><\/div><div id=\"field_5_3\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" ><label class='gfield_label gform-field-label' for='input_5_3'>Type of Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_5_3' class='large gfield_select'     aria-invalid=\"false\" ><option value='Auto Liability B.I.' >Auto Liability B.I.<\/option><option value='Auto - No-Fault' >Auto - No-Fault<\/option><option value='Disability' >Disability<\/option><option value='General Liability' >General Liability<\/option><option value='Health' >Health<\/option><option value='Home Owners' >Home Owners<\/option><option value='Other' >Other<\/option><option value='Workers&#039; Compnsation' >Workers&#039; Compnsation<\/option><\/select><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><h3 class=\"gsection_title\">Claimant Information<\/h3><\/div><div id=\"field_5_6\" 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_5_6\" ><label class='gfield_label gform-field-label' for='input_5_6'>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_6' id='input_5_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><label class='gfield_label gform-field-label' for='input_5_7'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" ><label class='gfield_label gform-field-label' for='input_5_9'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><label class='gfield_label gform-field-label' for='input_5_10'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_5_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_11\" 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_5_11\" ><label class='gfield_label gform-field-label' for='input_5_11'>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_11' id='input_5_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Social Security<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Date of Birth<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_14' id='input_5_14' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_14_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_14_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_14' class='gform_hidden' value='https:\/\/medlogix.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><label class='gfield_label gform-field-label' for='input_5_16'>Contact Person<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_5_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><label class='gfield_label gform-field-label' for='input_5_17'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_5_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><label class='gfield_label gform-field-label' for='input_5_18'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_5_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><label class='gfield_label gform-field-label' for='input_5_19'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><label class='gfield_label gform-field-label' for='input_5_20'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><label class='gfield_label gform-field-label' for='input_5_21'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><label class='gfield_label gform-field-label' for='input_5_22'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><h3 class=\"gsection_title\">Employer Information<\/h3><\/div><div id=\"field_5_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_5_24\" ><label class='gfield_label gform-field-label' for='input_5_24'>Employer 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_24' id='input_5_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_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_5_25\" ><label class='gfield_label gform-field-label' for='input_5_25'>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_25' id='input_5_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_26\" 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_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>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_26' id='input_5_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_27\" 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_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>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_27' id='input_5_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_28\" 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_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>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_28' id='input_5_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_29\" 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_5_29\" ><label class='gfield_label gform-field-label' for='input_5_29'>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_29' id='input_5_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_30\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><label class='gfield_label gform-field-label' for='input_5_30'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_5_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" ><label class='gfield_label gform-field-label' for='input_5_31'>Nature of Business<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_32\" 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_5_32\" ><label class='gfield_label gform-field-label' for='input_5_32'>Contact Person<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_32' id='input_5_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_33\" 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_5_33\" ><label class='gfield_label gform-field-label' for='input_5_33'>Contact 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_33' id='input_5_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><label class='gfield_label gform-field-label' for='input_5_34'>Contact Email<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_5_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><h3 class=\"gsection_title\">Carrier Information<\/h3><\/div><div id=\"field_5_36\" 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_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>Carrier Information<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_36' id='input_5_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_37\" 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_5_37\" ><label class='gfield_label gform-field-label' for='input_5_37'>Carrier<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_37' id='input_5_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" ><label class='gfield_label gform-field-label' for='input_5_38'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" ><label class='gfield_label gform-field-label' for='input_5_39'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><label class='gfield_label gform-field-label' for='input_5_40'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_5_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><label class='gfield_label gform-field-label' for='input_5_41'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Adjuster<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_5_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_43\" 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_5_43\" ><label class='gfield_label gform-field-label' for='input_5_43'>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_43' id='input_5_43' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><label class='gfield_label gform-field-label' for='input_5_44'>Fax<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_5_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\" ><label class='gfield_label gform-field-label' for='input_5_46'>Insured Amount<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" ><label class='gfield_label gform-field-label' for='input_5_47'>Policy Limit<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><label class='gfield_label gform-field-label' for='input_5_48'>Deductible Amount<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_5_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><h3 class=\"gsection_title\">Accident Information<\/h3><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\" ><label class='gfield_label gform-field-label' for='input_5_50'>Accident Date and Time<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_50' id='input_5_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><label class='gfield_label gform-field-label' for='input_5_51'>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_51' id='input_5_51' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Diagnosis<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_5_53' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_54\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_54\" ><label class='gfield_label gform-field-label' for='input_5_54'>Physician(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_5_54' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" ><label class='gfield_label gform-field-label' for='input_5_55'>Hospital(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_56\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\" ><label class='gfield_label gform-field-label' for='input_5_56'>Contact Phone or Beeper Number<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_5_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><h3 class=\"gsection_title\">Patient Attorney Information<\/h3><\/div><fieldset id=\"field_5_58\" 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_5_58\" ><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_5_58'>\n\t\t\t<div class='gchoice gchoice_5_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_5_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_0' id='label_5_58_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_5_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_5_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_59\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_59\" ><label class='gfield_label gform-field-label' for='input_5_59'>Attorney Name<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_5_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_60\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\" ><label class='gfield_label gform-field-label' for='input_5_60'>Firm Name<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_61\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><label class='gfield_label gform-field-label' for='input_5_61'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_5_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><label class='gfield_label gform-field-label' for='input_5_62'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_63\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><label class='gfield_label gform-field-label' for='input_5_63'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_5_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_64\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><label class='gfield_label gform-field-label' for='input_5_64'>Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_5_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_65\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><label class='gfield_label gform-field-label' for='input_5_65'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_5_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_66\" class=\"gfield gfield--type-text gfield--width-quarter 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