{"id":528,"date":"2017-12-28T05:49:52","date_gmt":"2017-12-28T11:49:52","guid":{"rendered":"http:\/\/doctortariq.com\/?page_id=528"},"modified":"2026-01-26T07:49:20","modified_gmt":"2026-01-26T13:49:20","slug":"insurance-appointment-request","status":"publish","type":"page","link":"https:\/\/tariqmd.com\/main\/home-5\/insurance-appointment-request\/","title":{"rendered":"BCBS, Aetna and Cigna only"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-color:rgba(173,242,247,0.87);--awb-bg-color-hover:rgba(173,242,247,0.87);--awb-bg-blend:overlay;--awb-bg-size:cover;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\" style=\"--awb-margin-right:10px;--awb-margin-left:10px;\"><p style=\"text-align: center;\"><strong>We accept BCBS, Cigna, Aetna, United, Oscar, UMR Compsych, Magellan, Allegiance, BoonChapman, Allegiance, Memorial health, kelsey united. <\/strong><\/p>\n<p style=\"text-align: center;\"><u>Unfortunately we do not take Medicaid, Ambetter, Molina . We also do not see Medicare patients<\/u>.<strong><\/strong><\/p>\n<p style=\"text-align: center;\"><strong>You can either fill out following form to verify your benefits with you insurance or just prepay the appointment and get a refund later, once insurance pays.<\/strong><\/p>\n<p style=\"text-align: center;\"><strong> If you prepaid the appointment, then there is no need to fill out this form.<\/strong><\/p>\n<p>If you will be using your insurance benefits to pay for your mental\/behavioral health services, please call your insurance company prior to your intake session with us to find out the answers to following questions. The number should be listed on the back of your card as member&#8217;s call number. You have option to fill out the following form online or <b><u><a style=\"color: #ff0000;\" href=\"https:\/\/tariqmd.com\/main\/wp-content\/uploads\/simple-file-list\/Questions-to-ask-from-your-insurance.pdf\">Click here to download and bring this completed form<\/a><\/u><\/b> or send it to us through email.<\/p>\n<p>Note: If you do not complete this form to your intake session, you might be charged the full contracted insurance rate for each session until you complete this task. We encourage you to take the time to call the #800 on the back of your insurance card to confirm your Mental\/Behavioral Health benefits.<\/p>\n<p>Insurance might ask our tax ID or NPI number. If they do, please use following information.<\/p>\n<p>Billing provider= Happy Minds Psychiatry PLLC; Tax ID: 813989390; Group\/Billing \u200bNPI: 1629515648<\/p>\n<p>Service Rendering provider= Mudassar Tariq, MD; \u200bNPI: 1588895825<\/p>\n<p>If they ask for CPT code, you can use 90837 and if they ask about a diagnosis, you can ask for any diagnosis (e.g Generalized Anxiety, code: F41.1)<\/p>\n<\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:80;line-height:1;\"><p style=\"text-align: center;\">Please fill out the form below<\/p><\/h1><\/div><div class=\"fusion-text fusion-text-2\"><p>The questions in following form will help you understand your benefits. You might have to call insurance or look in your insurance account online to get answers to these questions. Having answers to these questions will avoid any billing surprises later.<\/p>\n<p>Required questions are marked with an asterisk. This is because additional questions might appear or disappear depending on your answers to those required questions. We do require an email address and phone number in case we need to reach you.<\/p>\n<p>It is helpful to upload pictures of insurance card and your state ID, in case we need to do any additional verification on our end.<\/p>\n<p>After you fill out these forms, you will get an automated email with next steps. Please make sure to follow the link in automated email to request a portal account in our EMR Luminelllo. We will do further communication through the luminello portal to protect your privacy. Luminello is HIPAA compliant electronic medical record.<\/p>\n<\/div><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-2037\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-field-margin-top:7px;--awb-field-margin-bottom:7px;\" data-form-id=\"2037\" data-config=\"{&quot;form_id&quot;:&quot;2037&quot;,&quot;form_post_id&quot;:&quot;2037&quot;,&quot;post_id&quot;:528,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;redirect&quot;,&quot;redirect_url&quot;:&quot;https:\\\/\\\/happymind.clientsecure.me\\\/request\\\/service&quot;,&quot;redirect_timeout&quot;:&quot;0&quot;,&quot;field_labels&quot;:{&quot;whoispatient&quot;:&quot;Are you the patient, or you are filling out the form for someone else (child, sibling, spouse)?&quot;,&quot;firstname&quot;:&quot;Your First Name&quot;,&quot;last_name&quot;:&quot;Your Last Name&quot;,&quot;your_relationship_with_patient&quot;:&quot;Your relationship with patient (parent, spouse etc)?&quot;,&quot;Patients_first_name&quot;:&quot;Patient&#039;s First Name&quot;,&quot;patients_last_name&quot;:&quot;Patient&#039;s Last Name&quot;,&quot;date_of_birth&quot;:&quot;Patient&#039;s Date of Birth&quot;,&quot;email&quot;:&quot;Your email address&quot;,&quot;phone_number&quot;:&quot;Phone Number&quot;,&quot;address&quot;:&quot;Home Address&quot;,&quot;patients_email_address&quot;:&quot;Patient&#039;s email address&quot;,&quot;patients_phone_number&quot;:&quot;Patient&#039;s Phone Number&quot;,&quot;callednetwork&quot;:&quot;I confirmed that Dr. Mudassar Tariq (NPI 1588895825, Tax ID: 81-3989390) is in network with my insurance&quot;,&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network&quot;:&quot;If you have out of network benefits, do you want to see Dr. Mudassar Tariq, MD using your out of network benefits?&quot;,&quot;out_of_network_deductible&quot;:&quot;How much is your out of network deductible?&quot;,&quot;out_of_network_deductible_met&quot;:&quot;I have met following amount of out of network deductible&quot;,&quot;after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee&quot;:&quot;After I meet my out of network deductible, my insurance will reimburse me following percentage of fee paid to Happy Minds.&quot;,&quot;primary_insurance&quot;:&quot;What is your primary insurance?&quot;,&quot;insurance_id&quot;:&quot;Insurance Identification Number (ID)&quot;,&quot;group_number&quot;:&quot;Group Number&quot;,&quot;my_plan_type_is&quot;:&quot;My Plan type is&quot;,&quot;Deductible&quot;:&quot;Do you have a deductible for mental health (A certain dollar amount (e.g $1500) that you will have to pay first before insurance starts paying.))&quot;,&quot;how_much_is_your_deductible&quot;:&quot;How much is your deductible?&quot;,&quot;how_much_deductible_have_you_met&quot;:&quot;How much deductible have you met?&quot;,&quot;how_much_is_your_copay&quot;:&quot;How much is your copay?&quot;,&quot;who_is_the_main_subscriber_on_insurance_primary_insured&quot;:&quot;Who is the main subscriber on insurance (Primary insured)?&quot;,&quot;primary_insured&quot;:&quot;First and Last Name of primary insured&quot;,&quot;date_of_birth_primary_insured&quot;:&quot;Date Of Birth of primary insured&quot;,&quot;behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out&quot;:&quot;Is you behavioral health is managed by primary insurance or third party insurance carve out?&quot;,&quot;please_upload_front_side_of_insurance_card&quot;:&quot;Please upload front side of insurance card&quot;,&quot;please_upload_back_side_of_insurance_card&quot;:&quot;Please upload back side of insurance card.&quot;,&quot;upload_Identification&quot;:&quot;Please upload you state issued ID card (Driving license, Passport)&quot;},&quot;field_logics&quot;:{&quot;whoispatient&quot;:&quot;&quot;,&quot;firstname&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;your_relationship_with_patient&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;whoispatient\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;Patients_first_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;whoispatient\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;patients_last_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;whoispatient\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;date_of_birth&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;phone_number&quot;:&quot;&quot;,&quot;address&quot;:&quot;&quot;,&quot;patients_email_address&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;whoispatient\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;patients_phone_number&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;whoispatient\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;callednetwork&quot;:&quot;&quot;,&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;callednetwork\\&quot;,\\&quot;value\\&quot;:\\&quot;out_of_network\\&quot;}]&quot;,&quot;out_of_network_deductible&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\\&quot;,\\&quot;value\\&quot;:\\&quot;yes\\&quot;}]&quot;,&quot;out_of_network_deductible_met&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\\&quot;,\\&quot;value\\&quot;:\\&quot;yes\\&quot;}]&quot;,&quot;after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\\&quot;,\\&quot;value\\&quot;:\\&quot;yes\\&quot;}]&quot;,&quot;primary_insurance&quot;:&quot;&quot;,&quot;insurance_id&quot;:&quot;&quot;,&quot;group_number&quot;:&quot;&quot;,&quot;my_plan_type_is&quot;:&quot;&quot;,&quot;Deductible&quot;:&quot;&quot;,&quot;how_much_is_your_deductible&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;Deductible\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;how_much_deductible_have_you_met&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;Deductible\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;how_much_is_your_copay&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;Deductible\\&quot;,\\&quot;value\\&quot;:\\&quot;No\\&quot;}]&quot;,&quot;who_is_the_main_subscriber_on_insurance_primary_insured&quot;:&quot;&quot;,&quot;primary_insured&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;who_is_the_main_subscriber_on_insurance_primary_insured\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;date_of_birth_primary_insured&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;who_is_the_main_subscriber_on_insurance_primary_insured\\&quot;,\\&quot;value\\&quot;:\\&quot;someone_else\\&quot;}]&quot;,&quot;behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out&quot;:&quot;&quot;,&quot;please_upload_front_side_of_insurance_card&quot;:&quot;&quot;,&quot;please_upload_back_side_of_insurance_card&quot;:&quot;&quot;,&quot;upload_Identification&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;,&quot;submit_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;whoispatient&quot;:&quot;radio&quot;,&quot;firstname&quot;:&quot;text&quot;,&quot;last_name&quot;:&quot;text&quot;,&quot;your_relationship_with_patient&quot;:&quot;text&quot;,&quot;Patients_first_name&quot;:&quot;text&quot;,&quot;patients_last_name&quot;:&quot;text&quot;,&quot;date_of_birth&quot;:&quot;date&quot;,&quot;email&quot;:&quot;email&quot;,&quot;phone_number&quot;:&quot;phone_number&quot;,&quot;address&quot;:&quot;text&quot;,&quot;patients_email_address&quot;:&quot;email&quot;,&quot;patients_phone_number&quot;:&quot;phone_number&quot;,&quot;callednetwork&quot;:&quot;radio&quot;,&quot;do_you_want_to_see_dr_mudassar_tariq_md_out_of_network&quot;:&quot;radio&quot;,&quot;out_of_network_deductible&quot;:&quot;text&quot;,&quot;out_of_network_deductible_met&quot;:&quot;text&quot;,&quot;after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee&quot;:&quot;text&quot;,&quot;primary_insurance&quot;:&quot;text&quot;,&quot;insurance_id&quot;:&quot;text&quot;,&quot;group_number&quot;:&quot;text&quot;,&quot;my_plan_type_is&quot;:&quot;radio&quot;,&quot;Deductible&quot;:&quot;radio&quot;,&quot;how_much_is_your_deductible&quot;:&quot;text&quot;,&quot;how_much_deductible_have_you_met&quot;:&quot;text&quot;,&quot;how_much_is_your_copay&quot;:&quot;number&quot;,&quot;who_is_the_main_subscriber_on_insurance_primary_insured&quot;:&quot;radio&quot;,&quot;primary_insured&quot;:&quot;text&quot;,&quot;date_of_birth_primary_insured&quot;:&quot;date&quot;,&quot;behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out&quot;:&quot;text&quot;,&quot;please_upload_front_side_of_insurance_card&quot;:&quot;upload&quot;,&quot;please_upload_back_side_of_insurance_card&quot;:&quot;upload&quot;,&quot;upload_Identification&quot;:&quot;upload&quot;,&quot;notice_1&quot;:&quot;notice&quot;,&quot;recaptcha_1&quot;:&quot;recaptcha&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;,&quot;form_views&quot;:&quot;ajax&quot;,&quot;form_views_counting&quot;:&quot;all&quot;}\"><form action=\"https:\/\/tariqmd.com\/main\/home-5\/insurance-appointment-request\/\" method=\"post\" class=\"fusion-form fusion-form-2037\" enctype=\"multipart\/form-data\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-background-color:rgba(255,0,0,0.1);--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_6 1_6 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:16.666666666667%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:11.52%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:11.52%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_2_3 2_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:66.666666666667%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:2.88%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:2.88%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you the patient, or you are filling out the form for someone else (child, sibling, spouse)? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-whoispatient-1-0\" type=\"radio\" value=\"self\" name=\"whoispatient\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-whoispatient-1-0\">I am the patient<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-whoispatient-1-1\" type=\"radio\" value=\"someone_else\" name=\"whoispatient\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-whoispatient-1-1\">I am filling out form for a child or  someone else<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_6 1_6 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:16.666666666667%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:11.52%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:11.52%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"firstname\">Your First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"firstname\" id=\"firstname\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Your Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_3\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_relationship_with_patient\">Your relationship with patient (parent, spouse etc)?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"your_relationship_with_patient\" id=\"your_relationship_with_patient\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_4\"><div class=\"fusion-form-label-wrapper\"><label for=\"Patients_first_name\">Patient&#039;s First Name<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Patients_first_name\" id=\"Patients_first_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_5\"><div class=\"fusion-form-label-wrapper\"><label for=\"patients_last_name\">Patient&#039;s Last Name<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"patients_last_name\" id=\"patients_last_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><label for=\"date_of_birth\">Patient&#039;s Date of Birth <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><input autocomplete=\"off\" type=\"date\" data-first-day=\"0\"  data-format=\"\" tabindex=\"\" id=\"date_of_birth\" name=\"date_of_birth\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"autocomplete=\"no\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-3 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"email\">Your email address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"email\" autocomplete=\"off\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"phone_number\">Phone Number <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone-square-alt fas\"><\/i><input type=\"tel\" autocomplete=\"off\" name=\"phone_number\" id=\"phone_number\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"address\">Home Address<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"address\" id=\"address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"email_2\"><div class=\"fusion-form-label-wrapper\"><label for=\"patients_email_address\">Patient&#039;s email address<\/label><\/div><input type=\"email\" autocomplete=\"off\" name=\"patients_email_address\" id=\"patients_email_address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"phone_number_2\"><div class=\"fusion-form-label-wrapper\"><label for=\"patients_phone_number\">Patient&#039;s Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone-square-alt fas\"><\/i><input type=\"tel\" autocomplete=\"off\" name=\"patients_phone_number\" id=\"patients_phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-4 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">I confirmed that Dr. Mudassar Tariq (NPI 1588895825, Tax ID: 81-3989390) is in network with my insurance <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><div class=\"fusion-form-tooltip\"><i class=\"awb-icon-question-circle\"><\/i><span class=\"fusion-form-tooltip-content\">I have called the behavioral health phone number on the back of my insurance card and made sure that Dr. Mudassar Tariq (NPI 1588895825, Tax ID: 81-3989390) is in network<\/span><\/div><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-callednetwork-2-0\" type=\"radio\" value=\"in_network\" name=\"callednetwork\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-callednetwork-2-0\">Yes, Dr. Mudassar Tariq, MD is in network<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-callednetwork-2-1\" type=\"radio\" value=\"out_of_network\" name=\"callednetwork\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-callednetwork-2-1\">No, Dr. Mudassar Tariq, MD is not in network<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"radio_3\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">If you have out of network benefits, do you want to see Dr. Mudassar Tariq, MD using your out of network benefits?<\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-0\" type=\"radio\" value=\"yes\" name=\"do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-0\">yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-1\" type=\"radio\" value=\"no\" name=\"do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-1\">no<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-2\" type=\"radio\" value=\"No out of network benefits\" name=\"do_you_want_to_see_dr_mudassar_tariq_md_out_of_network\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_want_to_see_dr_mudassar_tariq_md_out_of_network-3-2\">No out of network benefits<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_7\"><div class=\"fusion-form-label-wrapper\"><label for=\"out_of_network_deductible\">How much is your out of network deductible?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"out_of_network_deductible\" id=\"out_of_network_deductible\" value=\"My out of network deductible is $\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_8\"><div class=\"fusion-form-label-wrapper\"><label for=\"out_of_network_deductible_met\">I have met following amount of out of network deductible<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"out_of_network_deductible_met\" id=\"out_of_network_deductible_met\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_9\"><div class=\"fusion-form-label-wrapper\"><label for=\"after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee\">After I meet my out of network deductible, my insurance will reimburse me following percentage of fee paid to Happy Minds.<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee\" id=\"after_i_meet_my_out_of_network_deductible_my_insurance_will_reimburse_me_following_percent_of_fee\" value=\"\"  class=\"fusion-form-input\" placeholder=\"e.g. 70% (if you pay $200, your insurance might reimburse you $140) \" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-5 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"primary_insurance\">What is your primary insurance? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"primary_insurance\" id=\"primary_insurance\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"BCBS, Cigna, Aetna etc *\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"insurance_id\">Insurance Identification Number (ID) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"insurance_id\" id=\"insurance_id\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"group_number\">Group Number<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"group_number\" id=\"group_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">My Plan type is<\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-my_plan_type_is-4-0\" type=\"radio\" value=\"PPO\" name=\"my_plan_type_is\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-my_plan_type_is-4-0\">PPO<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-my_plan_type_is-4-1\" type=\"radio\" value=\"HMO\" name=\"my_plan_type_is\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-my_plan_type_is-4-1\">HMO<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-my_plan_type_is-4-2\" type=\"radio\" value=\"Medicare\" name=\"my_plan_type_is\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-my_plan_type_is-4-2\">Medicare<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-my_plan_type_is-4-3\" type=\"radio\" value=\"I am not sure\" name=\"my_plan_type_is\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-my_plan_type_is-4-3\">I am not sure<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have a deductible for mental health (A certain dollar amount (e.g $1500) that you will have to pay first before insurance starts paying.)) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-deductible-5-0\" type=\"radio\" value=\"Yes\" name=\"Deductible\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-deductible-5-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-deductible-5-1\" type=\"radio\" value=\"No\" name=\"Deductible\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-deductible-5-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_13\"><div class=\"fusion-form-label-wrapper\"><label for=\"how_much_is_your_deductible\">How much is your deductible?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"how_much_is_your_deductible\" id=\"how_much_is_your_deductible\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_14\"><div class=\"fusion-form-label-wrapper\"><label for=\"how_much_deductible_have_you_met\">How much deductible have you met?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"how_much_deductible_have_you_met\" id=\"how_much_deductible_have_you_met\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"number_1\"><div class=\"fusion-form-label-wrapper\"><label for=\"how_much_is_your_copay\">How much is your copay?<\/label><\/div><input type=\"number\" autocomplete=\"off\" name=\"how_much_is_your_copay\" id=\"how_much_is_your_copay\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"100\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Who is the main subscriber on insurance (Primary insured)? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-who_is_the_main_subscriber_on_insurance_primary_insured-6-0\" type=\"radio\" value=\"me\" name=\"who_is_the_main_subscriber_on_insurance_primary_insured\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-who_is_the_main_subscriber_on_insurance_primary_insured-6-0\">Me<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-who_is_the_main_subscriber_on_insurance_primary_insured-6-1\" type=\"radio\" value=\"someone_else\" name=\"who_is_the_main_subscriber_on_insurance_primary_insured\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-who_is_the_main_subscriber_on_insurance_primary_insured-6-1\">Someone else<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"text_15\"><div class=\"fusion-form-label-wrapper\"><label for=\"primary_insured\">First and Last Name of primary insured<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"primary_insured\" id=\"primary_insured\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"2037\" data-form-element-name=\"date_2\"><label for=\"date_of_birth_primary_insured\">Date Of Birth of primary insured<\/label><input autocomplete=\"off\" type=\"date\" data-first-day=\"0\"  data-format=\"\" tabindex=\"\" id=\"date_of_birth_primary_insured\" name=\"date_of_birth_primary_insured\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\"autocomplete=\"no\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-6 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\"><p>In some HMO plans, the mental health is contracted out to third party insurance. You might not even be aware of the name of that insurance. Few examples are Magellan, compsych, Beacon, optum etc.\u00a0 We are in network with Magellan and Compsych but not with Beacon and Optum. So we just want you to be aware, that if it is a third party carve out, even if your card says Blue Cross Blue Sheild, we might not be in network and you might be billed for full fee. If you are not sure, just google the behavioral\/mental health phone number on the back of your insurance card, or you can call that number and ask them this question.<\/p>\n<\/div>\n<div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div class=\"fusion-form-label-wrapper\"><label for=\"behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out\">Is you behavioral health is managed by primary insurance or third party insurance carve out?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out\" id=\"behavioral_health_is_managed_by_primary_insurance_or_third_party_carve_out\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Primary Insurance or third party carve out (Magellan, Compsych, Optum, Beacon) \" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-7 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above\" style=\"--awb-preview-thumb-width:115px;\" data-form-id=\"2037\"><label for=\"please_upload_front_side_of_insurance_card\">Please upload front side of insurance card<\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"please_upload_front_side_of_insurance_card\" name=\"please_upload_front_side_of_insurance_card\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera \" data-size=\"2\" data-single-add-remove=\"no\" data-min-upload-files=\"0\" data-max-upload-files=\"0\" data-uploads-preview=\"filenames\"\/><div class=\"fusion-form-upload-field\"  data-holds-private-data=\"false\"><span class=\"awb-upload-placeholder\" data-default=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera\">Click or drag a file to this area to upload, or take a picture directly with cell phone camera<\/span><div class=\"awb-uploads-preview\"><div class=\"awb-preview-thumbs\"><\/div><\/div><\/div><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;width:calc(100%);\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above\" style=\"--awb-preview-thumb-width:115px;\" data-form-id=\"2037\"><label for=\"please_upload_back_side_of_insurance_card\">Please upload back side of insurance card.<\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"please_upload_back_side_of_insurance_card\" name=\"please_upload_back_side_of_insurance_card\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera \" data-size=\"2\" data-single-add-remove=\"no\" data-min-upload-files=\"0\" data-max-upload-files=\"0\" data-uploads-preview=\"filenames\"\/><div class=\"fusion-form-upload-field\"  data-holds-private-data=\"false\"><span class=\"awb-upload-placeholder\" data-default=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera\">Click or drag a file to this area to upload, or take a picture directly with cell phone camera<\/span><div class=\"awb-uploads-preview\"><div class=\"awb-preview-thumbs\"><\/div><\/div><\/div><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-2 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;width:calc(100%);\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above\" style=\"--awb-preview-thumb-width:115px;\" data-form-id=\"2037\"><label for=\"upload_Identification\">Please upload you state issued ID card (Driving license, Passport)<\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"upload_Identification\" name=\"upload_Identification\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera \" data-size=\"2\" data-single-add-remove=\"no\" data-min-upload-files=\"0\" data-max-upload-files=\"0\" data-uploads-preview=\"filenames\"\/><div class=\"fusion-form-upload-field\"  data-holds-private-data=\"false\"><span class=\"awb-upload-placeholder\" data-default=\"Click or drag a file to this area to upload, or take a picture directly with cell phone camera\">Click or drag a file to this area to upload, or take a picture directly with cell phone camera<\/span><div class=\"awb-uploads-preview\"><div class=\"awb-preview-thumbs\"><\/div><\/div><\/div><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-3 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;width:calc(100%);\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-8 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for filling out the form. Your information has been submitted. As a confirmation, we will be sending you a link to request a chart in our system. Please check your email and follow further directions.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-9 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_4 1_4 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:7.68%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_4 1_4 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:7.68%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-recaptcha-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\">\t\t\t\t<div class=\"form-creator-recaptcha\" >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"fusion-form-recaptcha-wrapper\">\n\t\t\t\t\t<div\n\t\t\t\t\t\tid=\"g-recaptcha-id-form-2037\"\n\t\t\t\t\t\tclass=\"awb-recaptcha-v2 fusion-form-recaptcha-v2\"\n\t\t\t\t\t\tdata-theme=\"light\"\n\t\t\t\t\t\tdata-sitekey=\"6LdnKQEVAAAAAK25xZX3X-rSEdhNxlk6NCheaCtA\"\n\t\t\t\t\t\tdata-tabindex=\"\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_4 1_4 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:7.68%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"2037\"><div ><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-4 fusion-button-default-span  button-default form-form-submit\" style=\"width:calc(100%);\" data-form-number=\"2037\" tabindex=\"\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Submit<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_4 1_4 fusion-flex-column\" 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