{"id":59,"date":"2019-04-12T15:10:31","date_gmt":"2019-04-12T19:10:31","guid":{"rendered":"http:\/\/nortonhealthcaretest1.flywheelsites.com\/?page_id=59"},"modified":"2026-06-17T11:29:21","modified_gmt":"2026-06-17T15:29:21","slug":"financial-assistance","status":"publish","type":"page","link":"https:\/\/nortonhealthcare.com\/patient-resources\/billing-information\/financial-assistance\/","title":{"rendered":"Financial Assistance"},"content":{"rendered":"\n<h2 id=\"h-helping-to-take-the-stress-out-of-paying-your-bills\" class=\"wp-block-heading\">Helping to Take the Stress Out of Paying Your Bills<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Norton Healthcare\u2019s purpose is to provide quality health care to all those we serve, in a manner that responds to the needs of our communities and honors our faith heritage.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">As part of our mission, the Norton Healthcare Financial Assistance Policy covers hospital-based emergency or other medically necessary care to patients who cannot afford to pay and who qualify for financial assistance based on income, resources and family situation.<\/p>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-constrained wp-block-group-is-layout-constrained\">\n<p class=\"wp-block-paragraph\">At Norton Healthcare and Norton Children\u2019s, families with income equal to or less than 350% of the federal poverty level may be eligible for financial assistance. This expansion of eligibility makes financial assistance available to more middle-income families and individuals in our community. For example, a family of four with a combined household income of up to $115,500 per year may qualify.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-constrained wp-block-group-is-layout-constrained\"><\/div><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">In addition, applications can be made at any time.<\/p>\n\n\n<div class=\"card float-xl-end ms-xl-3 my-4 w-xl-50\">\n\t<div class=\"card-body \">\n\t\t\t\t\n\n<h2 id=\"h-questions-answered\" class=\"wp-block-heading\">Questions Answered<\/h2>\n\n\n \n    <div class=\"ratio ratio-16x9 my-5\">\n      <iframe src=\"https:\/\/www.youtube.com\/embed\/LMEuya8IB_s\" allowfullscreen><\/iframe>\n    <\/div>\n\n\n\n \n    <div class=\"ratio ratio-16x9 my-5\">\n      <iframe src=\"https:\/\/www.youtube.com\/embed\/Eki-bM36ark\" allowfullscreen><\/iframe>\n    <\/div>\n\n\n\n\n<h3 id=\"h-read-more\" class=\"wp-block-heading\">Read More<\/h3>\n\n\n\n<figure class=\"wp-block-image size-large rounded\"><img decoding=\"async\" src=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2023\/02\/thomas-williams-financial-assistance-program.png\" alt=\"\"\/><\/figure>\n\n\n\n<h5 id=\"h-middle-income-louisville-man-benefits-from-expanded-health-care-assistance-program\" class=\"wp-block-heading\"><a href=\"https:\/\/nortonhealthcare.com\/news\/middle-income-louisville-man-benefits-from-expanded-health-care-assistance-policy\/\">Middle-income Louisville man benefits from expanded health care assistance program<\/a><\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">Expanded financial assistance program at Norton Healthcare gives a Louisville man new hope and an opportunity for better health. Find out how you can apply.<\/p>\n\n\n\t<\/div>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\">Financial Assistance Eligibility<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">You may qualify for free or discounted emergency or medically necessary care if you meet all of the following criteria:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>You do not have health insurance, or you have an unpaid balance after your insurance plan has either paid or rejected a claim.<\/li>\n\n\n\n<li>You do not qualify for subsidized coverage or government assistance, such as Disproportionate Share Hospital Program, Children\u2019s Health Insurance Program (CHIP), Medicaid, Medicaid managed care organization or Hoosier Healthwise.<\/li>\n\n\n\n<li>Your family unit\u2019s income is equal to or less than 350% of the federal poverty guidelines.<\/li>\n\n\n\n<li>Your family unit\u2019s resources (assets) are equal to or less than 200% of the Disproportionate Share Hospital guidelines.<\/li>\n\n\n\n<li>For additional financial assistance criteria, refer to the Norton Healthcare Financial Assistance Policy.<\/li>\n<\/ul>\n\n\n\n\n\n<h2 class=\"wp-block-heading\">Applying for Financial Assistance<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">To apply for financial assistance, you must submit an application and three months of bank statements for each bank account for the household. You may be also be asked to provide a copy of your last year\u2019s tax return or other documents, as required by the financial assistance policy. Once a determination is made, you will receive a response from our financial assistance department. Provide all the information requested so that we may accurately assess your need for assistance that could help you get the care you need.<\/p>\n\n\n\n<h3 id=\"h-request-an-application\" class=\"wp-block-heading\">Request an Application<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">You also can get an application at any Norton Healthcare emergency department, or call customer service at <a href=\"tel:(502) 479-6300\"><strong>(502) 479-6300<\/strong> <\/a>or <a href=\"tel:(800)%20874-3979\"><strong>(800) 874-3979<\/strong><\/a> to request an application to be mailed to you for free.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Financial counselors at any of our hospitals can answer questions. You also can call Norton Healthcare customer service at <a href=\"tel:+15024796300\"><strong>(502) 479-6300<\/strong><\/a> or <a href=\"tel:+18008743979\"><strong>(800) 874-3979<\/strong><\/a>.<\/p>\n\n\n\n<h3 id=\"h-download-an-application\" class=\"wp-block-heading\">Download an Application<\/h3>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/NORTON-HEALTHCARE-APPLICATION-FOR-FINANCIAL-ASSISTANCE-effective-1-1-2023-updated-lockbox-1.pdf\">Application for Financial Assistance<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/\u0637\u0644\u0628-\u0627\u0644\u062a\u0642\u062f\u0645-\u0644\u0644\u062d\u0635\u0648\u0644-\u0639\u0644\u0649-\u0627\u0644\u0627\u0655\u0639\u0627\u0646\u0629-\u0627\u0644\u0645\u0627\u0644\u064a\u0629-\u0627\u0644\u062e\u0627\u0635\u0629-\u0628\u0646\u0638\u0627\u0645-NORTON-HEALTHCARE-Financial-Assistance-application-1-1-23-Arabic-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0637\u0644\u0628 \u0627\u0644\u062a\u0642\u062f\u0645 \u0644\u0644\u062d\u0635\u0648\u0644 \u0639\u0644\u0649 \u0627\u0644\u0627\u0655\u0639\u0627\u0646\u0629 \u0627\u0644\u0645\u0627\u0644\u064a\u0629 \u0627\u0644\u062e\u0627\u0635\u0629 \u0628\u0646\u0638\u0627\u0645<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/ZAHTJEV-ZA-FINANCIJSKU-POMOC\u0301-PRUZ\u030cATELJA-ZDRAVSTVENE-SKRBI-NORTON-HEALTHCARE-financial-assistance-application-Serbian-Croatian-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">ZAHTJEV ZA FINANCIJSKU POMOC\u0301<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/SOLICITUD-PARA-OBTENER-AYUDA-ECONO\u0301MICA-DE-NORTON-HEALTHCARE-financial-assistance-application-Spanish-9-30-23-.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">SOLICITUD PARA OBTENER AYUDA ECONO\u0301MICA<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/DO\u031bN-XIN-HO\u0302\u0303-TRO\u031b\u0323-TA\u0300I-CHI\u0301NH-TU\u031b\u0300-NORTON-HEALTHCARE-financial-assistance-application-Vietnamese-9-30-23-.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0110O\u031bN XIN HO\u0302\u0303 TRO\u031b\u0323 TA\u0300I CHI\u0301NH<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/OMBI-LA-USAIDIZI-WA-KIFEDHA-KWA-NORTON-HEALTHCARE-financial-assistance-application-Swahili-9-30-23-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">OMBI LA USAIDIZI WA KIFEDHA<\/a><\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/NORTON-HEALTHCARE-\u8ca1\u52d9\u63f4\u52a9\u7533\u8acb-Financial-Assistance-Application-Chinese-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u8ca1\u52d9\u63f4\u52a9\u7533\u8acb<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/\u0906\u0930\u094d\u0925\u093f\u0915-\u0938\u0939\u093e\u092f\u0924\u093e\u0915\u094b-\u0932\u093e\u0917\u093f-Norton-Healthcare-\u0906\u0935\u0947\u0926\u0928-financial-assistance-application-Nepali-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0906\u0930\u094d\u0925\u093f\u0915 \u0938\u0939\u093e\u092f\u0924\u093e\u0915\u094b \u0932\u093e\u0917\u093f  \u0906\u0935\u0947\u0926\u0928<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/UBUSABE-BW-NHC-financial-assistance-application-Kinyarwanda-9-30-23.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">UBUSABE BW\u2019UBUFASHA BW\u2019AMAFARANGA MU IVURIRO RYA NORTON<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/NHC-Financial-Assistance-application-French-09-30-23-.pdf\">DEMANDE D\u2019AIDE FINANCI\u00c8RE<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/ANTRAG-AUF-FINANZIELLE-UNTERSTU\u0308TZUNG-DURCH-NORTON-HEALTHCARE-financial-assistance-application-German-9-30-23-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">ANTRAG AUF FINANZIELLE UNTERSTU\u0308TZUNG<\/a><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2024\/03\/CODSIGA-DARYEELKA-CAAFIMAADKA-NORTON-EE-GARGAARKA-MAALIYADA-NHC-Financial-assistance-application-Somali-9-30-23-1-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">CODSIGA DARYEELKA CAAFIMAADKA NORTON EE GARGAARKA MAALIYADA<\/a><\/p>\n<\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\">If you complete a downloaded application or a paper application, you can scan it and email it to <a href=\"http:\/\/FAP@nortonhealthcare.org\"><strong>FAP@nortonhealthcare.org<\/strong><\/a>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You also can mail applications to:<\/p>\n\n\n\n<p class=\"has-text-align-left wp-block-paragraph\">Norton Healthcare<br>SBO Financial Assistance, Dept. 14-7<br>P.O. Box 35070<br>Louisville, KY 40232-9972<\/p>\n\n\n\n<h3 id=\"h-apply-online\" class=\"wp-block-heading\">Apply Online<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Note: The information you provide is encrypted and submitted securely. It is used only for the purpose of qualification for financial assistance. Read our <a href=\"https:\/\/nortonhealthcare.com\/privacy-policy\" target=\"_blank\" rel=\"noreferrer noopener\">privacy policy<\/a> to learn more.<\/p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Financial Assistance Application<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_69'  action='\/wp-json\/wp\/v2\/pages\/59' data-formid='69' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_69' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_69_134\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_134'>Account Number<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_69_134' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_14\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_69_14'>\n                            \n                            <span id='input_69_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_69_14_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_69_14_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_69_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_69_14_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_69_14_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_69_2\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_69_2' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_2_1_container'><label for='input_69_2_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_2[]' id='input_69_2_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_2_2_container'><label for='input_69_2_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_2[]' id='input_69_2_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_2_3_container'><label for='input_69_2_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_2[]' id='input_69_2_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_18'>SSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_69_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_133\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_69_133' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_69_133_1_container' >\n                                        <input type='text' name='input_133.1' id='input_69_133_1' value=''    aria-required='true'    \/>\n                                        <label for='input_69_133_1' id='input_69_133_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_69_133_2_container' >\n                                        <input type='text' name='input_133.2' id='input_69_133_2' value=''     aria-required='false'   \/>\n                                        <label for='input_69_133_2' id='input_69_133_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_69_133_3_container' >\n                                    <input type='text' name='input_133.3' id='input_69_133_3' value=''    aria-required='true'    \/>\n                                    <label for='input_69_133_3' id='input_69_133_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_69_133_4_container' >\n                                        <select name='input_133.4' id='input_69_133_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_69_133_4' id='input_69_133_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_69_133_5_container' >\n                                    <input type='text' name='input_133.5' id='input_69_133_5' value=''    aria-required='true'    \/>\n                                    <label for='input_69_133_5' id='input_69_133_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_133.6' id='input_69_133_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_69_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_69_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_69_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_3'>Home phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_69_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_19\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_19'>Mobile phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_69_19' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is patient a U.S. citizen?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_69_20'>\n\t\t\t<div class='gchoice gchoice_69_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_69_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_20_0' id='label_69_20_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_69_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_69_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_20_1' id='label_69_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_69_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is patient a legal U.S. resident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_69_21'>\n\t\t\t<div class='gchoice gchoice_69_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_69_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_21_0' id='label_69_21_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_69_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_69_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_21_1' id='label_69_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_69_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_22'>Patient&#039;s employer<\/label><div class='gfield_description' id='gfield_description_69_22'>If minor, parent&#8217;s info<\/div><div class='ginput_container ginput_container_text'><input name='input_22' id='input_69_22' type='text' value='' class='medium'  aria-describedby=\"gfield_description_69_22\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_17\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_17'>Employer phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_69_17' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_23\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_23'>Spouse&#039;s employer<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_69_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_24\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_24'>Employer phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_69_24' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">If You Have Health Insurance, Please Provide<\/h3><\/div><div id=\"field_69_26\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_26'>Company name<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_69_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_27\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_27'>Company phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_69_27' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_28\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_28'>Policy #<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_69_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_29\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Policy holder name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_69_29'>\n                            \n                            <span id='input_69_29_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_69_29_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_29.3' id='input_69_29_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_69_29_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_69_29_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_29.6' id='input_69_29_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_69_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Was this stay due to a car accident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_69_30'>\n\t\t\t<div class='gchoice gchoice_69_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_69_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_30_0' id='label_69_30_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_69_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_69_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_30_1' id='label_69_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_69_31\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Accident date<\/legend><div id='input_69_31' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_31_1_container'><label for='input_69_31_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_31[]' id='input_69_31_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_31_2_container'><label for='input_69_31_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_31[]' id='input_69_31_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_31_3_container'><label for='input_69_31_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_31[]' id='input_69_31_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_33\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_33'>Accident Attorney information<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_69_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is account related to Workers Compensation?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_69_34'>\n\t\t\t<div class='gchoice gchoice_69_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_69_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_34_0' id='label_69_34_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_69_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_69_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_69_34_1' id='label_69_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_69_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Injury date<\/legend><div id='input_69_35' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_35_1_container'><label for='input_69_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_69_35_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_35_2_container'><label for='input_69_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_69_35_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_35_3_container'><label for='input_69_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_69_35_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_36\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_36'>Workers Compensation Attorney information<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_69_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">List the Name, Age and Relationship of Members in Household to the Patient:<\/h3><\/div><div id=\"field_69_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_38'>Household member 1 name<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_69_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_157\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Household Member 1 Date of Birth<\/legend><div id='input_69_157' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_157_1_container'><label for='input_69_157_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_157[]' id='input_69_157_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_157_2_container'><label for='input_69_157_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_157[]' id='input_69_157_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_157_3_container'><label for='input_69_157_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_157[]' id='input_69_157_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_40'>Household member 1 relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_69_40' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_44'>Household member 2 name<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_69_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_158\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Household member 2 Date of Birth<\/legend><div id='input_69_158' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_158_1_container'><label for='input_69_158_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_158[]' id='input_69_158_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_158_2_container'><label for='input_69_158_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_158[]' id='input_69_158_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_158_3_container'><label for='input_69_158_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_158[]' id='input_69_158_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_46'>Household member 2 relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_69_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_47'>Household member 3 name<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_69_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_159\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Household member 3 Date of Birth<\/legend><div id='input_69_159' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_159_1_container'><label for='input_69_159_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_159[]' id='input_69_159_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_159_2_container'><label for='input_69_159_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_159[]' id='input_69_159_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_159_3_container'><label for='input_69_159_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_159[]' id='input_69_159_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_49'>Household member 3 relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_69_49' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_50'>Household member 4 name<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_69_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_160\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Household member 4 Date of Birth<\/legend><div id='input_69_160' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_160_1_container'><label for='input_69_160_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_160[]' id='input_69_160_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_160_2_container'><label for='input_69_160_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_160[]' id='input_69_160_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_160_3_container'><label for='input_69_160_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_160[]' id='input_69_160_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_55\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_55'>Household member 4 relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_69_55' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_53'>Household member 5 name<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_69_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_161\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Household member 5 Date of Birth<\/legend><div id='input_69_161' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_69_161_1_container'><label for='input_69_161_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_161[]' id='input_69_161_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_69_161_2_container'><label for='input_69_161_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_161[]' id='input_69_161_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_69_161_3_container'><label for='input_69_161_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_161[]' id='input_69_161_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_69_52\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_52'>Household member 5 relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_69_52' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gross Income (Monthly)<\/h3><div class='gsection_description' id='gfield_description_69_56'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><\/div><div id=\"field_69_162\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_162'>Patient&#039;s income<\/label><div class='gfield_description' id='gfield_description_69_162'>If patient is a minor, Mom&#8217;s monthly income<\/div><div class='ginput_container ginput_container_number'><input name='input_162' id='input_69_162' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_162\" \/><\/div><\/div><div id=\"field_69_163\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_163'>Spouse&#039;s income<\/label><div class='gfield_description' id='gfield_description_69_163'>If patient is a minor, Dad&#8217;s monthly income<\/div><div class='ginput_container ginput_container_number'><input name='input_163' id='input_69_163' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_163\" \/><\/div><\/div><div id=\"field_69_59\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_59'>If you have no income, who pays for your expenses?<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_69_59' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_60\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other Gross Income (Monthly)<\/h3><div class='gsection_description' id='gfield_description_69_60'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><\/div><div id=\"field_69_165\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_165'>K-TAP<\/label><div class='ginput_container ginput_container_number'><input name='input_165' id='input_69_165' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_166\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_166'>Social Security<\/label><div class='ginput_container ginput_container_number'><input name='input_166' id='input_69_166' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_167\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_167'>SSI \/ Disability<\/label><div class='ginput_container ginput_container_number'><input name='input_167' id='input_69_167' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_168\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_168'>Unemployment<\/label><div class='ginput_container ginput_container_number'><input name='input_168' id='input_69_168' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_169\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_169'>Food Stamps<\/label><div class='ginput_container ginput_container_number'><input name='input_169' id='input_69_169' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_170\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_170'>Pension<\/label><div class='ginput_container ginput_container_number'><input name='input_170' id='input_69_170' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_131\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_131'>Other income<\/label><div class='ginput_container ginput_container_number'><input name='input_131' id='input_69_131' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_69\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_69'>TOTAL MONTHLY INCOME<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_69_69'>This field will automatically total above fields <\/div><div class='ginput_container ginput_container_number'><input name='input_69' id='input_69_69' type='text' step='any'   value='' class='medium gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_69_69\" \/><\/div><\/div><div id=\"field_69_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Expenses (Monthly)<\/h3><div class='gsection_description' id='gfield_description_69_71'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><\/div><div id=\"field_69_78\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_78'>Rent \/ Mortgage<\/label><div class='ginput_container ginput_container_number'><input name='input_78' id='input_69_78' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_79\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_79'>Telephone<\/label><div class='ginput_container ginput_container_number'><input name='input_79' id='input_69_79' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_82\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_82'>Food and Supplies<\/label><div class='ginput_container ginput_container_number'><input name='input_82' id='input_69_82' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_81\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_81'>Utilities<\/label><div class='ginput_container ginput_container_number'><input name='input_81' id='input_69_81' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_80\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_80'>Other Expenses<\/label><div class='ginput_container ginput_container_number'><input name='input_80' id='input_69_80' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_69_83\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_83'>Total monthly expenses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_69_83'>This field will automatically total above fields <\/div><div class='ginput_container ginput_container_number'><input name='input_83' id='input_69_83' type='text' step='any'   value='' class='medium gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_69_83\" \/><\/div><\/div><div id=\"field_69_84\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Countable Resources<\/h3><\/div><div id=\"field_69_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_85'>Checking account bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_69_85' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_94\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_94'>Checking account value<\/label><div class='gfield_description' id='gfield_description_69_94'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_94' id='input_69_94' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_94\" \/><\/div><\/div><div id=\"field_69_135\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_135'>Savings account bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_69_135' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_136\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_136'>Savings account value<\/label><div class='gfield_description' id='gfield_description_69_136'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_136' id='input_69_136' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_136\" \/><\/div><\/div><div id=\"field_69_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_92'>Money market bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_69_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_102\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_102'>Money market value<\/label><div class='gfield_description' id='gfield_description_69_102'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_102' id='input_69_102' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_102\" \/><\/div><\/div><div id=\"field_69_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_91'>Mutual fund bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_69_91' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_101\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_101'>Mutual fund value<\/label><div class='gfield_description' id='gfield_description_69_101'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_101' id='input_69_101' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_101\" \/><\/div><\/div><div id=\"field_69_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_93'>401(k) name<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_69_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_100\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_100'>401(k) value<\/label><div class='gfield_description' id='gfield_description_69_100'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_100' id='input_69_100' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_100\" \/><\/div><\/div><div id=\"field_69_90\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_90'>403(b) name<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_69_90' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_99\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_99'>403(b) value<\/label><div class='gfield_description' id='gfield_description_69_99'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_99' id='input_69_99' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_99\" \/><\/div><\/div><div id=\"field_69_89\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_89'>Bonds bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_69_89' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_98\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_98'>Bonds value<\/label><div class='gfield_description' id='gfield_description_69_98'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_98' id='input_69_98' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_98\" \/><\/div><\/div><div id=\"field_69_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_88'>IRA bank name<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_69_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_97\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_97'>IRA value<\/label><div class='gfield_description' id='gfield_description_69_97'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_97' id='input_69_97' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_97\" \/><\/div><\/div><div id=\"field_69_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_87'>Other resources<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_69_87' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_96\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_96'>Other resources value<\/label><div class='gfield_description' id='gfield_description_69_96'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_96' id='input_69_96' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_96\" \/><\/div><\/div><div id=\"field_69_95\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_95'>Total resources<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_69_95'>This field will automatically total above fields <\/div><div class='ginput_container ginput_container_number'><input name='input_95' id='input_69_95' type='text' step='any'   value='' class='medium gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_69_95\" \/><\/div><\/div><div id=\"field_69_103\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Property<\/h3><\/div><div id=\"field_69_104\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_104'>Home mortgagee<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_69_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_106\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_106'>Current home value<\/label><div class='gfield_description' id='gfield_description_69_106'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_106' id='input_69_106' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_106\" \/><\/div><\/div><div id=\"field_69_109\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_109'>Current home equity<\/label><div class='gfield_description' id='gfield_description_69_109'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_109' id='input_69_109' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_109\" \/><\/div><\/div><div id=\"field_69_107\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_107'>Other property mortgagee<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_69_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_108\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_108'>Other property current value<\/label><div class='gfield_description' id='gfield_description_69_108'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_108' id='input_69_108' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_108\" \/><\/div><\/div><div id=\"field_69_105\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_105'>Other property current equity<\/label><div class='gfield_description' id='gfield_description_69_105'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_105' id='input_69_105' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_105\" \/><\/div><\/div><div id=\"field_69_111\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_111'>Other homes mortgagee<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_69_111' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_110\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_110'>Other homes value<\/label><div class='gfield_description' id='gfield_description_69_110'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_110' id='input_69_110' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_110\" \/><\/div><\/div><div id=\"field_69_112\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_112'>Other homes equity<\/label><div class='gfield_description' id='gfield_description_69_112'>Please enter a numerical value <br>\nExamples: 123.45, 500, 1000<\/div><div class='ginput_container ginput_container_number'><input name='input_112' id='input_69_112' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_69_112\" \/><\/div><\/div><div id=\"field_69_121\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_121'>Other Homes? Please provide Mortagee name, address, current value and current equity<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_121' id='input_69_121' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_69_126\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>THIS CERTIFIES THAT I REQUEST TO BE CONSIDERED FOR FINANCIAL ASSISTANCE AT NORTON HEALTHCARE.<\/p>\n\n<p>I HEREBY AGREE to furnish Norton Healthcare with the information necessary to determine my eligibility for assistance with the medical bills resulting from the services I have received at their facilities. I understand that my physicians and other health care providers may have financial assistance policies that could assist me with the medical bills from those providers. As such, I authorize Norton Healthcare to provide a copy of my application to those providers who request it to assist them in determining whether I qualify for benefits under their financial assistance programs.<\/p>\n\n<p>I certify that the information provided by me in this application is correct and true to the best of my knowledge and belief. I understand that if I give false information or withhold information in applying for assistance, my application will be denied and Norton Healthcare will continue to pursue collection of any outstanding balance due. In that instance, I may also be subject to prosecution for fraud.<\/p>\n\n<p>I agree to notify Norton Healthcare of any changes to the information provided in this form including address, telephone number, and income.<\/p><\/div><fieldset id=\"field_69_130\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_69_130'>By checking here I certify that I have read and understand the above paragraphs, and that I request to be considered for financial assistance for hospital charges at <strong>Norton Healthcare<\/strong>.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_69_130'><div class='gchoice gchoice_69_130_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_130.1' type='checkbox'  value='Yes'  id='choice_69_130_1'   aria-describedby=\"gfield_description_69_130\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_69_130_1' id='label_69_130_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_69_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_128'>Responsible party name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_69_128' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_70\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_70'>CAPTCHA<\/label><div id='input_69_70' class='ginput_container ginput_recaptcha' data-sitekey='6LcoMwoTAAAAAGT4yj9f8zcY0-ZdtYP7epI0KaVP'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_69_132\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_132'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_132' id='input_69_132' type='text' value='06\/23\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_69_132_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_69_132_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_69_132' class='gform_hidden' value='https:\/\/nortonhealthcare.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_69' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_69' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_69' id='gform_theme_69' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_69' id='gform_style_settings_69' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_69' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='69' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='QN2AnYVCWUHnnxm9aSCXKwj6t0LLpk7Jf63z+a9+d0NAUDhz0C\/volO2b++xeOJSKDOt+vqMv2ejJss4GSlCdt7DsK1N3QN1zvQ0ycZlaOFXZoY=' \/>\n            <input type='hidden' 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{gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_69').val();gformInitSpinner( 69, 'https:\/\/nortonhealthcare.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [69, current_page]);window['gf_submitting_69'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_69').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [69]);window['gf_submitting_69'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_69').text());}else{jQuery('#gform_69').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"69\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                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attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n\n\n\n<h2 class=\"wp-block-heading\">If You Aren\u2019t Eligible<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">If you aren\u2019t eligible for help under the financial assistance policy, payment plan options are available. This could be the result of not meeting the eligibility requirements of if your care was not for a hospital-based emergency or otherwise medically necessary.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Call Norton Healthcare customer service at <a href=\"tel:(502) 479-6300\"><strong>(502) 479-6300<\/strong><\/a> or <a href=\"tel:+18008743979\"><strong>(800) 874-3979<\/strong><\/a> for more information. Contact us as soon as you become aware you may need to set up a payment plan.<\/p>\n\n\n\n<h2 id=\"h-what-will-i-be-charged-for-care\" class=\"wp-block-heading\">What Will I Be Charged for Care?<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Norton Healthcare provides hospital-based emergency and other medically necessary care free of charge to all patients who meet the criteria for the Financial Assistance Policy. Patients who are eligible for financial assistance will not be charged more than the amounts generally billed to patients with insurance coverage. This includes care at Norton Healthcare\u2019s six hospitals, plus Norton Children\u2019s Medical Center, Norton Cancer Institute, Norton Cardiovascular Diagnostic Centers and Norton Diagnostic Centers.<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h2 id=\"h-policies-and-disclosures\" class=\"wp-block-heading\">Policies and Disclosures<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.2.2025.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Amounts Generally Billed (AGB)<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12-03-2025-English.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Financial Assistance Policy<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.2025-English.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Plain Language Summary<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.2025-English.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Billing and Collections Policy<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-eng.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Provider Listing<\/a><\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h2 class=\"wp-block-heading has-text-align-right\" id=\"h-\u0627\u0644\u0633\u064a\u0627\u0633\u0627\u062a-\u0648\u0627\u0644\u0625\u0641\u0635\u0627\u062d\u0627\u062a\">\u0627\u0644\u0633\u064a\u0627\u0633\u0627\u062a \u0648\u0627\u0644\u0625\u0641\u0635\u0627\u062d\u0627\u062a<\/h2>\n\n\n\n<p class=\"has-text-align-right wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.2.2025-Arabic.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u062d\u0633\u0627\u0628 \u0627\u0644\u0645\u0628\u0644\u063a \u0627\u0644\u0645\u0641\u0631\u0648\u0636 \u0628\u0634\u0643\u0644 \u0639\u0627\u0645<\/a><\/p>\n\n\n\n<p class=\"has-text-align-right wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Arabic.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0629 \u0627\u0625\u0644\u0639\u0627\u0646\u0629 \u0633\u064a\u0627\u0633<\/a><\/p>\n\n\n\n<p class=\"has-text-align-right wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.2025-Arabic.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0645\u0644\u062e\u0635 \u0628\u0644\u063a\u0629 \u0645\u0628\u0633\u0637\u0629<\/a><\/p>\n\n\n\n<p class=\"has-text-align-right wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Arabic.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0633\u064a\u0627\u0633\u0629 \u0627\u0644\u0641\u0648\u062a\u0631\u0629 \u0648\u0627\u0644\u062a\u062d\u0635\u064a\u0644 &#8211; \u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644 \u064f\u0645\u0642\u062f\u0645\u0629 \u0628\u0627\u0644\u0645\u0633\u062a\u0634\u0641\u064a\u0627\u062a<\/a><\/p>\n\n\n\n<p class=\"has-text-align-right wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-ara.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0642\u0627\u0626\u0645\u0629 \u0627\u0644\u0645\u0648\u0641\u0631<\/a><\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h2 id=\"h-politike-i-objave\" class=\"wp-block-heading\">Politike i objave<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.02.25-Serbian.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Izra\u010dun iznosa koji se obi\u010dno napla\u0107uje<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12-03-2025-Croatian.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">POLITIKA FINANSIJSKE POMO\u0106I<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Serbian.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Sa\u017eetak jednostavnim jezikom<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Serbian.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">PRAVILO O FAKTURIRANJU I NAPLATI \u2013 BOLNI\u010cKA MEDICINSKA SKRB<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-hrv.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Popis pru\u017eatelja usluga<\/a><\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h2 id=\"h-politicas-y-divulgaciones\" class=\"wp-block-heading\">Pol\u00edticas y divulgaciones<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-6.02.25-Spanish.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">C\u00e1lculo de las cantidades generalmente facturadas<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Spanish.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">POL\u00cdTICA DE ASISTENCIA ECON\u00d3MICA<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Spanish.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Resumen en lenguaje sencillo<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Spanish.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">POL\u00cdTICA DE FACTURACI\u00d3N Y COBRO &#8211; ATENCI\u00d3N M\u00c9DICA HOSPITALARIA<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-spa.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Listado de proveedores<\/a><\/p>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-chinh-sach-va-ti\u1ebft-l\u1ed9\" class=\"wp-block-heading\">Ch\u00ednh s\u00e1ch v\u00e0 Ti\u1ebft l\u1ed9<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.2.25-Vietnamese.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">T\u00ednh To\u00e1n S\u1ed1 Ti\u1ec1n \u0110\u01b0\u1ee3c L\u1eadp H\u00f3a \u0110\u01a1n Th\u00f4ng Th\u01b0\u1eddng<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Vietnamese.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">CH\u00cdNH S\u00c1CH H\u1ed6 TR\u1ee2 T\u00c0I CH\u00cdNH<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Vietnamese.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">T\u00f3m t\u1eaft ng\u00f4n ng\u1eef \u0111\u01a1n gi\u1ea3n<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Vietnamese.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">CH\u00cdNH S\u00c1CH H\u00d3A \u0110\u01a0N V\u00c0 THU PH\u00cd &#8211; CH\u0102M S\u00d3C Y T\u1ebe T\u1ea0I B\u1ec6NH VI\u1ec6N<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-vie.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Danh s\u00e1ch nh\u00e0 cung c\u1ea5p<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-sera-na-ufichuzi\" class=\"wp-block-heading\">Sera na Ufichuzi<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/fap-providers-swa.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Hesabu ya Kiasi Kinachotozwa Kwa Kawaida<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Swahili.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">SERA YA USAIDIZI WA KIFEDHA&nbsp;<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Swahili.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Muhtasari wa Usaidizi wa Kifedha kwa Huduma za Dharura za Hospitali au Huduma<br>za Matibabu Zinazohitajika za Kiafya<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Swahili.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">SERA YA MALIPO NA MAKUSANYO &#8211; HUDUMA<br>YA MATIBABU YA HOSPITALINI<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-swa.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Orodha ya Watoa Huduma<\/a><\/p>\n<\/div><\/div>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-\u653f\u7b56\u548c\u63ed\u9732\" class=\"wp-block-heading\">\u653f\u7b56\u548c\u63ed\u9732<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.2.2025_Chinese-Traditional.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u822c\u6536\u8cbb\u91d1\u984d\u8a08\u7b97<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.03.2025-Chinese-Traditional.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u8ca1\u52d9\u63f4\u52a9\u653f\u7b56<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Chinese-Traditional.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u91ab\u9662\u6025\u8a3a\u6216\u91ab\u7642\u5fc5\u9700\u8b77\u7406\u8ca1\u52d9\u63f4\u52a9\u6458\u8981<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Chinese-Traditional.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u8a08\u8cbb\u8207\u6536\u6b3e\u653f\u7b56 &#8211; \u91ab\u9662\u91ab\u7642\u8b77\u7406<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-zho.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u63d0\u4f9b\u8005\u5217\u8868<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-\u0928-\u0924-\u0939\u0930-\u0930-\u0916-\u0932-\u0938-\u0939\u0930\" class=\"wp-block-heading\">\u0928\u0940\u0924\u093f\u0939\u0930\u0942 \u0930 \u0916\u0941\u0932\u093e\u0938\u093e\u0939\u0930\u0942<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.02.25-Nepali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0930\u0915\u092e \u0938\u093e\u092e\u093e\u0928\u094d\u092f\u0924\u092f\u093e \u092c\u093f\u0932 \u0917\u0930\u0930\u090f\u0915\u094b \u0917\u0923\u0928\u093e<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Nepali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0906\u0930\u094d\u0925\u093f\u0915 \u0938\u0939\u093e\u092f\u0924\u093e \u0928\u0940\u0930\u094d\u0924<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Nepali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u0905\u00e8\u092a\u0924\u093e\u0932\u092e\u093e \u0906\u0927\u093e\u093f\u0930\u0924 \u0906\u0915\u093f\u00e8\u092e\u0915 \u0935\u093e \u093f\u091a\u093f\u0915\u00d7\u0938\u0915\u0940\u092f \u01fe\u092a\u092e\u093e \u0906\u0935\u00e6\u092f\u0915 \u0939\u0947\u0930\u091a\u093e\u0939\u0915\u094b \u0932\u093e\u093f\u0917 \u0906\u093f\u0925\u0915\u0930\u094d \u0938\u0939\u093e\u092f\u0924\u093e\u0915\u094b \u0938\u093e\u0930\u093e\u0936<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Nepali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u092c\u093f\u092c\u093f\u0919 \u0930 \u0938\u0919\u094d\u0915\u093f\u0928 \u0928\u0940\u092c\u093f &#8211; \u0905\u0938\u094d\u092a\u093f\u093e\u093f\u092e\u093e \u0906\u0927\u093e\u0930\u0930\u093f \u092c\u093f\u092c\u093f\u0924\u094d\u0938\u093e \u0939\u0947\u0930\u093f\u093e\u0939<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-nep.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">\u092a\u094d\u0930\u0926\u093e\u092f\u0915 \u0938\u0942\u091a\u0940<\/a><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-politiki-no-kumenyekanisha\" class=\"wp-block-heading\">Politiki no Kumenyekanisha<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/fap-providers-kin.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Ibarwa ry\u2019amafaranga yatanzwe kuri fagitire muri rusange<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Kinyarwanda.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">AMABWIRIZA AGENGA ITANGWA<br>RY\u2019UBUFASHA BW\u2019AMAFARANGA<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.2025-Kinyarwanda.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Incamake y\u2019ubufasha bw\u2019amafaranga ku buvuzi buwhutirwa butagirwa mu bitaro<br>cyangwa ubuvuzi bwa ngombwa<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Kinyarwanda.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">AMABWIRIZA AGENGA IKORWA RYA<br>FAGITIRE N\u2019IKUSANYWA RY\u2019AMAFARANGA &#8211;<br>UBUVUZI BUTANGIRWA MU BITARO<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-kin.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Urutonde rwabatanga<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-politiques-et-divulgations\" class=\"wp-block-heading\">Politiques et divulgations<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.02.25-French.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Calcul des montants g\u00e9n\u00e9ralement factur\u00e9s<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.03.2025-French.pdf\">POLITIQUE D\u2019AIDE FINANCI\u00c8RE<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-French.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">R\u00e9sum\u00e9 de l\u2019aide financi\u00e8re pour les soins hospitaliers d\u2019urgence ou m\u00e9dicalement<br>n\u00e9cessaires<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-French.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">POLITIQUE DE FACTURATION ET<br>RECOUVREMENT \u2013 SOINS M\u00c9DICAUX EN<br>H\u00d4PITAL<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-fre.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Liste des fournisseurs<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-richtlinien-und-offenlegungen\" class=\"wp-block-heading\">Richtlinien und Offenlegungen<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/06\/Norton-AGB-Calculation-4853-1826-1893-v4-ENG-6.02.25-German.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Berechnung der allgemeinen Verrechnungss\u00e4tze<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-German.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">RICHTLINIE ZUR FINANZIELLEN<br>UNTERST\u00dcTZUNG<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-German.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Informationen zur finanziellen Unterst\u00fctzung f\u00fcr die Notfall- oder anderweitig<br>medizinisch notwendige Versorgung im Krankenhaus<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-German.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">RICHTLINIE ZUM ABRECHNUNGS- UND<br>INKASSOVERFAHREN \u2013 MEDIZINISCHE<br>VERSORGUNG IM KRANKENHAUS<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-ger.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Anbieterliste<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 id=\"h-siyaasadaha-iyo-shaacinta\" class=\"wp-block-heading\">Siyaasadaha iyo Shaacinta<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/fap-providers-som.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Guud ahaan Qadarka Xisaabta Biilka Lagusoo dallacay<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-4815-4822-7651-v28-12.3.2025-Somali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">SIYAASADA KAALMADA DHAQAALAHA<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Financial-Assistance-Policy-Summary-4850-8939-9875-v13-12.3.25-Somali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Soo koobida Kaalmada Dhaqaalaha Dagdagga ee Isbitaalka ku Saleysan ama<br>Daryeelka Caafimaadka Lagama maarmaanka ah<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2025\/12\/Norton-Healthcare-Billing-and-Collection-Policy-4847-8682-0163-v24-12.3.25-Somali.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">SIYAASADA URUURINTA IYO BIIL<br>DALLACSIINTA \u2013 DARYEELKA<br>CAAFIMAADKA KU SALEYSAN ISBITAALKA<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/nortonhealthcare.com\/wp-content\/uploads\/2026\/06\/fap-providers-som.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Liiska Bixiyaha<\/a><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n\n\n \n    <div class=\"row\">\n      <div class=\"col-xl-8 mx-auto\">\n        <div class=\"ratio ratio-16x9 my-5\">\n          <iframe src=\"https:\/\/www.youtube.com\/embed\/Ufzi88Cvw3w\" allowfullscreen><\/iframe>\n        <\/div>\n      <\/div>\n    <\/div>\n    \n","protected":false},"excerpt":{"rendered":"<p>Helping to Take the Stress Out of Paying Your Bills Norton Healthcare\u2019s purpose is to provide quality health care to all those we serve, in a manner that responds to&#8230;<\/p>\n","protected":false},"author":15,"featured_media":37419,"parent":58,"menu_order":1,"comment_status":"open","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-59","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.8 (Yoast SEO v27.8) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Financial Assistance | Louisville, Ky. | Norton Healthcare<\/title>\n<meta name=\"description\" content=\"Information about financial assistance at Norton Healthcare and how to apply for financial assistance at a Norton Healthcare facility in Louisville, Ky.\" 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