stagfe2/resources/views/app/new-patient.blade.php

@extends ('layouts.template')

@section('content')

    <?php $patients = [1,2,3,4]; ?>

    <div class="p-3 mcp-theme-1" id="newPatientContainer">
        <div class="col-12 col-lg-6 px-0">
            <div class="card d-block mb-3" moe="">

                <div class="card-header">
                    <strong>
                        <i class="fas fa-user-plus"></i>
                        New Patient
                    </strong>
                </div>
                <div class="card-body">
                    <form show url="/api/client/create" class="px-3 pt-3 pb-1 primary-form" redir="patients/view/[data]">
                        @if (session('message'))
                            <div class="alert alert-danger">{{ session('message') }}</div>
                        @endif
                        <div class='form-group mb-3'>
                            <label class='control-label'>First Name *</label>
                            <input class='form-control' type='text' name='nameFirst' required>
                        </div>
                        <div class='form-group mb-3'>
                            <label class='control-label'>Last Name *</label>
                            <input class='form-control' type='text' name='nameLast' value='' required>
                        </div>
			
                        <div class='form-group mb-3'>
                            <label class='control-label'>Sex</label>
                            <select class='form-control' name='sex' value='' >
                                <option value=''>-- Select --</option>
                                <option value='M'>M</option>
                                <option value='F'>F</option>
                            </select>
                        </div>
                        <div class='form-group mb-3'>
                            <label class='control-label'>Date Of Birth *</label>
                            <input class='form-control' type='date' name='dateOfBirth' max="{{ date('Y-m-d') }}" required>
                        </div>
                        <div class='form-group mb-3'>
                            <label class='control-label d-flex align-items-center'>
                                <span>Home Phone Number</span>
                                <a href="#"
                                   class="ml-2 px-1 on-hover-opaque hpn-to-cpn">
                                    <i class="fa fa-arrow-down"></i>
                                </a>
                                <a href="#"
                                   class="ml-2 px-1 on-hover-opaque swap-pns">
                                    <i class="fa fa-retweet"></i>
                                </a>
                            </label>
                            <input class='form-control' stag-input-phone type='tel' name='homeNumber'>
                        </div>
                        <div class='form-group mb-3'>
                            <label class='control-label d-flex align-items-center'>
                                <span>Cell Phone Number</span>
                                <a href="#"
                                   class="ml-2 px-1 on-hover-opaque cpn-to-hpn">
                                    <i class="fa fa-arrow-up"></i>
                                </a>
                            </label>
                            <input class='form-control' stag-input-phone type='tel' name='cellNumber'>
                        </div>
                        <div class='form-group mb-3'>
                            <label class='control-label'>Email Address </label>
                            <input class='form-control' type='email' name='emailAddress'>
                        </div>
                        <hr class="m-neg-4">
                        <div class='form-group mb-3 d-flex align-items-center'>
                            <label class='my-0 mr-3 control-label'>Insurance </label>
                            <div class="d-inline-flex align-items-center">
                                <label class="my-0 mr-3 d-inline-flex align-items-center">
                                    <input class='insurance' type='radio' name='insurance' value="medicare" checked>
                                    <span class="ml-1">Medicare</span>
                                </label>
                                <label class="my-0 mr-3 d-inline-flex align-items-center">
                                    <input class='insurance' type='radio' name='insurance' value="non-medicare">
                                    <span class="ml-1">Non-Medicare</span>
                                </label>
                            </div>
                        </div>
                        <div data-insurance="medicare">
                            <div class='form-group mb-3'>
                                <label class='control-label'>Medicare Number</label>
                                <input class='form-control' type='text' name='medicareNumber'>
                            </div>
                        </div>
                        <div data-insurance="non-medicare" class="d-none">
                            <div class='form-group mb-3'>
                                <label class='control-label d-block'>Payer</label>
                                <select name="mbPayerUid" class="form-control select2">
                                    <option value="">--select--</option>
                                    <option value="1199SEIU">1199SEIU</option>
                                    <option value="1st Agency">1st Agency</option>
                                    <option value="20/20 Eyecare Plan">20/20 Eyecare Plan</option>
                                    <option value="AARP">AARP</option>
                                    <option value="ACE">ACE</option>
                                    <option value="AIG">AIG</option>
                                    <option value="APWU">APWU</option>
                                    <option value="ATRIO Health Plans">ATRIO Health Plans</option>
                                    <option value="AVMA Life">AVMA Life</option>
                                    <option value="Absolute Total Care">Absolute Total Care</option>
                                    <option value="Access Medicare (NY)">Access Medicare (NY)</option>
                                    <option value="Accountable Health Plan of Ohio">Accountable Health Plan of Ohio</option>
                                    <option value="Advanced Health">Advanced Health</option>
                                    <option value="AdvantageMD">AdvantageMD</option>
                                    <option value="Advantica">Advantica</option>
                                    <option value="Advent Health">Advent Health</option>
                                    <option value="Adventist Health">Adventist Health</option>
                                    <option value="Advocate Health Care">Advocate Health Care</option>
                                    <option value="Aetna">Aetna</option>
                                    <option value="Aetna Better Health">Aetna Better Health</option>
                                    <option value="Affinity Health Plan">Affinity Health Plan</option>
                                    <option value="AgeWell New York">AgeWell New York</option>
                                    <option value="Agile Health Insurance">Agile Health Insurance</option>
                                    <option value="Alameda Alliance for Health">Alameda Alliance for Health</option>
                                    <option value="Aliera Health Care">Aliera Health Care</option>
                                    <option value="Alignment Health Plan">Alignment Health Plan</option>
                                    <option value="All Savers Insurance">All Savers Insurance</option>
                                    <option value="AllCare Health">AllCare Health</option>
                                    <option value="AllState">AllState</option>
                                    <option value="AllWays Health Partners">AllWays Health Partners</option>
                                    <option value="Allegiance Life and Health">Allegiance Life and Health</option>
                                    <option value="Alliant Health Plans">Alliant Health Plans</option>
                                    <option value="Allianz Worldwide Care">Allianz Worldwide Care</option>
                                    <option value="Allwell">Allwell</option>
                                    <option value="AlohaCare">AlohaCare</option>
                                    <option value="AlphaCare">AlphaCare</option>
                                    <option value="AltaMed Senior BuenaCare (PACE)">AltaMed Senior BuenaCare (PACE)</option>
                                    <option value="Altius (Coventry Health Care)">Altius (Coventry Health Care)</option>
                                    <option value="AlwaysCare">AlwaysCare</option>
                                    <option value="Ambetter">Ambetter</option>
                                    <option value="AmeriGroup">AmeriGroup</option>
                                    <option value="AmeriHealth">AmeriHealth</option>
                                    <option value="AmeriHealth Caritas">AmeriHealth Caritas</option>
                                    <option value="America's 1st Choice">America's 1st Choice</option>
                                    <option value="American Behavioral">American Behavioral</option>
                                    <option value="American Eldercare">American Eldercare</option>
                                    <option value="American Healthcare Alliance">American Healthcare Alliance</option>
                                    <option value="American Maritime Officers Plans">American Maritime Officers Plans</option>
                                    <option value="American Republic Insurance Company">American Republic Insurance Company</option>
                                    <option value="Amida Care">Amida Care</option>
                                    <option value="Amplifon Hearing Health Care">Amplifon Hearing Health Care</option>
                                    <option value="Anthem Blue Cross">Anthem Blue Cross</option>
                                    <option value="Anthem Blue Cross Blue Shield">Anthem Blue Cross Blue Shield</option>
                                    <option value="Apostrophe">Apostrophe</option>
                                    <option value="ArchCare">ArchCare</option>
                                    <option value="Arise Health Plan">Arise Health Plan</option>
                                    <option value="Arizona Complete Health">Arizona Complete Health</option>
                                    <option value="Arizona Foundation for Medical Care">Arizona Foundation for Medical Care</option>
                                    <option value="Arkansas Blue Cross Blue Shield">Arkansas Blue Cross Blue Shield</option>
                                    <option value="Arkansas Total Care">Arkansas Total Care</option>
                                    <option value="Ascension Complete">Ascension Complete</option>
                                    <option value="Ascension Health">Ascension Health</option>
                                    <option value="Assurant Employee Benefits">Assurant Employee Benefits</option>
                                    <option value="Assurant Health">Assurant Health</option>
                                    <option value="Asuris Northwest Health">Asuris Northwest Health</option>
                                    <option value="Aultcare">Aultcare</option>
                                    <option value="AvMed">AvMed</option>
                                    <option value="Avera Health Plans">Avera Health Plans</option>
                                    <option value="Avesis">Avesis</option>
                                    <option value="BMC HealthNet Plan">BMC HealthNet Plan</option>
                                    <option value="Banker's Life">Banker's Life</option>
                                    <option value="Banner Health">Banner Health</option>
                                    <option value="Baptist Health Plan">Baptist Health Plan</option>
                                    <option value="BayCarePlus Medicare Advantage">BayCarePlus Medicare Advantage</option>
                                    <option value="Beacon Health Options">Beacon Health Options</option>
                                    <option value="Beaumont Employee Health Plan">Beaumont Employee Health Plan</option>
                                    <option value="Beech Street">Beech Street</option>
                                    <option value="Best Choice Plus">Best Choice Plus</option>
                                    <option value="Best Doctors Insurance">Best Doctors Insurance</option>
                                    <option value="Best Life And Health">Best Life And Health</option>
                                    <option value="Better Health (Florida Medicaid)">Better Health (Florida Medicaid)</option>
                                    <option value="Bind HealthCare">Bind HealthCare</option>
                                    <option value="Blue Choice Health Plan">Blue Choice Health Plan</option>
                                    <option value="Blue Cross Blue Shield (BCBS)">Blue Cross Blue Shield (BCBS)</option>
                                    <option value="Blue Cross Blue Shield Federal Employee Program">Blue Cross Blue Shield Federal Employee Program</option>
                                    <option value="Blue Cross Blue Shield of Alabama">Blue Cross Blue Shield of Alabama</option>
                                    <option value="Blue Cross Blue Shield of Arizona">Blue Cross Blue Shield of Arizona</option>
                                    <option value="Blue Cross Blue Shield of Georgia">Blue Cross Blue Shield of Georgia</option>
                                    <option value="Blue Cross Blue Shield of Illinois">Blue Cross Blue Shield of Illinois</option>
                                    <option value="Blue Cross Blue Shield of Kansas">Blue Cross Blue Shield of Kansas</option>
                                    <option value="Blue Cross Blue Shield of Kansas City">Blue Cross Blue Shield of Kansas City</option>
                                    <option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
                                    <option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
                                    <option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
                                    <option value="Blue Cross Blue Shield of Minnesota">Blue Cross Blue Shield of Minnesota</option>
                                    <option value="Blue Cross Blue Shield of Mississippi">Blue Cross Blue Shield of Mississippi</option>
                                    <option value="Blue Cross Blue Shield of Montana">Blue Cross Blue Shield of Montana</option>
                                    <option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
                                    <option value="Blue Cross Blue Shield of New Mexico">Blue Cross Blue Shield of New Mexico</option>
                                    <option value="Blue Cross Blue Shield of North Carolina">Blue Cross Blue Shield of North Carolina</option>
                                    <option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
                                    <option value="Blue Cross Blue Shield of Oklahoma">Blue Cross Blue Shield of Oklahoma</option>
                                    <option value="Blue Cross Blue Shield of Rhode Island">Blue Cross Blue Shield of Rhode Island</option>
                                    <option value="Blue Cross Blue Shield of South Carolina">Blue Cross Blue Shield of South Carolina</option>
                                    <option value="Blue Cross Blue Shield of Tennessee">Blue Cross Blue Shield of Tennessee</option>
                                    <option value="Blue Cross Blue Shield of Texas">Blue Cross Blue Shield of Texas</option>
                                    <option value="Blue Cross Blue Shield of Vermont">Blue Cross Blue Shield of Vermont</option>
                                    <option value="Blue Cross Blue Shield of Western New York">Blue Cross Blue Shield of Western New York</option>
                                    <option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
                                    <option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
                                    <option value="Blue Cross of Northeastern Pennsylvania">Blue Cross of Northeastern Pennsylvania</option>
                                    <option value="Blue Shield of California">Blue Shield of California</option>
                                    <option value="Blue Shield of Northeastern New York">Blue Shield of Northeastern New York</option>
                                    <option value="Brand New Day">Brand New Day</option>
                                    <option value="Braven Health (Horizon Blue Cross Blue Shield of New Jersey)">Braven Health (Horizon Blue Cross Blue Shield of New Jersey)</option>
                                    <option value="BridgeSpan">BridgeSpan</option>
                                    <option value="Bridgeway Health Solutions">Bridgeway Health Solutions</option>
                                    <option value="Bright Health">Bright Health</option>
                                    <option value="Buckeye Health Plan">Buckeye Health Plan</option>
                                    <option value="CBA Blue">CBA Blue</option>
                                    <option value="CDPHP">CDPHP</option>
                                    <option value="CHAMPVA">CHAMPVA</option>
                                    <option value="CHP Group">CHP Group</option>
                                    <option value="CHRISTUS Health Plan">CHRISTUS Health Plan</option>
                                    <option value="CalOptima">CalOptima</option>
                                    <option value="CalPERS">CalPERS</option>
                                    <option value="CalViva Health">CalViva Health</option>
                                    <option value="California Foundation for Medical Care">California Foundation for Medical Care</option>
                                    <option value="California Health and Wellness">California Health and Wellness</option>
                                    <option value="Calvos">Calvos</option>
                                    <option value="Cambridge Health Alliance (CHA)">Cambridge Health Alliance (CHA)</option>
                                    <option value="Capital Blue Cross">Capital Blue Cross</option>
                                    <option value="Capital Health Plan">Capital Health Plan</option>
                                    <option value="Care Access Health Plan">Care Access Health Plan</option>
                                    <option value="Care Improvement Plus">Care Improvement Plus</option>
                                    <option value="Care N' Care">Care N' Care</option>
                                    <option value="Care1st">Care1st</option>
                                    <option value="CareConnect">CareConnect</option>
                                    <option value="CareFirst Blue Cross Blue Shield">CareFirst Blue Cross Blue Shield</option>
                                    <option value="CareMore">CareMore</option>
                                    <option value="CareOregon">CareOregon</option>
                                    <option value="CarePartners of Connecticut">CarePartners of Connecticut</option>
                                    <option value="CarePlus Health Plans (Florida Medicare)">CarePlus Health Plans (Florida Medicare)</option>
                                    <option value="CareSource">CareSource</option>
                                    <option value="Cascade Health Alliance">Cascade Health Alliance</option>
                                    <option value="Caterpillar">Caterpillar</option>
                                    <option value="CeltiCare Health Plan">CeltiCare Health Plan</option>
                                    <option value="CenCal Health">CenCal Health</option>
                                    <option value="Cenpatico">Cenpatico</option>
                                    <option value="Centennial Care">Centennial Care</option>
                                    <option value="Center for Elders' Independence (PACE)">Center for Elders' Independence (PACE)</option>
                                    <option value="CenterLight Healthcare">CenterLight Healthcare</option>
                                    <option value="Centers Plan for Healthy Living">Centers Plan for Healthy Living</option>
                                    <option value="Centers for Medicare &amp; Medicaid Services">Centers for Medicare &amp; Medicaid Services</option>
                                    <option value="Centivo">Centivo</option>
                                    <option value="Centra Health">Centra Health</option>
                                    <option value="Central California Alliance for Health">Central California Alliance for Health</option>
                                    <option value="Central Health Plan of California">Central Health Plan of California</option>
                                    <option value="Century Healthcare - CHC">Century Healthcare - CHC</option>
                                    <option value="Children's Community Health Plan">Children's Community Health Plan</option>
                                    <option value="Children's Medical Center Health Plan">Children's Medical Center Health Plan</option>
                                    <option value="Children's Medical Services (CMS)">Children's Medical Services (CMS)</option>
                                    <option value="Chinese Community Health Plan">Chinese Community Health Plan</option>
                                    <option value="Choice Care Network">Choice Care Network</option>
                                    <option value="Christian Healthcare Ministries">Christian Healthcare Ministries</option>
                                    <option value="Cigna">Cigna</option>
                                    <option value="Cigna-HealthSpring">Cigna-HealthSpring</option>
                                    <option value="Clarion Health">Clarion Health</option>
                                    <option value="Clark County Self-Funded Health">Clark County Self-Funded Health</option>
                                    <option value="Clear Spring Health">Clear Spring Health</option>
                                    <option value="Clements Worldwide">Clements Worldwide</option>
                                    <option value="Cleveland Clinic Employee Health Plan">Cleveland Clinic Employee Health Plan</option>
                                    <option value="Clover Health">Clover Health</option>
                                    <option value="Cofinity">Cofinity</option>
                                    <option value="Colorado Access">Colorado Access</option>
                                    <option value="Columbia Pacific CCO">Columbia Pacific CCO</option>
                                    <option value="Columbia United Providers">Columbia United Providers</option>
                                    <option value="ComPsych">ComPsych</option>
                                    <option value="Common Ground Healthcare Cooperative">Common Ground Healthcare Cooperative</option>
                                    <option value="Commonwealth Care Alliance">Commonwealth Care Alliance</option>
                                    <option value="Community Behavioral Health">Community Behavioral Health</option>
                                    <option value="Community Care Alliance of Illinois">Community Care Alliance of Illinois</option>
                                    <option value="Community Care Associates">Community Care Associates</option>
                                    <option value="Community Care Behavioral Health Organization">Community Care Behavioral Health Organization</option>
                                    <option value="Community Care Plan">Community Care Plan</option>
                                    <option value="Community Care of North Carolina">Community Care of North Carolina</option>
                                    <option value="Community Eye Care">Community Eye Care</option>
                                    <option value="Community First Health Plans">Community First Health Plans</option>
                                    <option value="Community Health Choice">Community Health Choice</option>
                                    <option value="Community Health Group">Community Health Group</option>
                                    <option value="Community Health Options">Community Health Options</option>
                                    <option value="Community Health Partners">Community Health Partners</option>
                                    <option value="Community Health Plan of Washington">Community Health Plan of Washington</option>
                                    <option value="CommunityCare of Oklahoma">CommunityCare of Oklahoma</option>
                                    <option value="CompBenefits">CompBenefits</option>
                                    <option value="Companion Life">Companion Life</option>
                                    <option value="Comprehensive Health Insurance Plan (CHIP) of Illinois">Comprehensive Health Insurance Plan (CHIP) of Illinois</option>
                                    <option value="Comprehensive Medical and Dental Program (CMDP)">Comprehensive Medical and Dental Program (CMDP)</option>
                                    <option value="Connect Care">Connect Care</option>
                                    <option value="ConnectiCare">ConnectiCare</option>
                                    <option value="Consolidated Health Plans">Consolidated Health Plans</option>
                                    <option value="Constitution Life">Constitution Life</option>
                                    <option value="Consumer Health Network">Consumer Health Network</option>
                                    <option value="Contra Costa Health Plan">Contra Costa Health Plan</option>
                                    <option value="Cook Children's Health Plan">Cook Children's Health Plan</option>
                                    <option value="Coordinated Care Health">Coordinated Care Health</option>
                                    <option value="Corvel">Corvel</option>
                                    <option value="CountyCare (Cook County)">CountyCare (Cook County)</option>
                                    <option value="Coventry Health Care">Coventry Health Care</option>
                                    <option value="Cox HealthPlans">Cox HealthPlans</option>
                                    <option value="Create">Create</option>
                                    <option value="Crystal Run Health Plans">Crystal Run Health Plans</option>
                                    <option value="Culinary Health Fund">Culinary Health Fund</option>
                                    <option value="DAKOTACARE">DAKOTACARE</option>
                                    <option value="DC Medicaid">DC Medicaid</option>
                                    <option value="DMC Care">DMC Care</option>
                                    <option value="DOCS (Doctors of the Oregon South Coast)">DOCS (Doctors of the Oregon South Coast)</option>
                                    <option value="DavidShield">DavidShield</option>
                                    <option value="Davis Vision">Davis Vision</option>
                                    <option value="Deaconess Health Plans">Deaconess Health Plans</option>
                                    <option value="Dean Health Plan">Dean Health Plan</option>
                                    <option value="Denver Health Medical Plan">Denver Health Medical Plan</option>
                                    <option value="Department of Medical Assistance Services">Department of Medical Assistance Services</option>
                                    <option value="Deseret Mutual">Deseret Mutual</option>
                                    <option value="Devon Health Services">Devon Health Services</option>
                                    <option value="Devoted Health">Devoted Health</option>
                                    <option value="Dimension Health">Dimension Health</option>
                                    <option value="Doctors HealthCare Plans">Doctors HealthCare Plans</option>
                                    <option value="Driscoll Health Plan">Driscoll Health Plan</option>
                                    <option value="EHP Significa">EHP Significa</option>
                                    <option value="EMI Health">EMI Health</option>
                                    <option value="ESSENCE Healthcare">ESSENCE Healthcare</option>
                                    <option value="Eastern Oregon Coordinated Care Organization">Eastern Oregon Coordinated Care Organization</option>
                                    <option value="Easy Choice Health Plan (California)">Easy Choice Health Plan (California)</option>
                                    <option value="Easy Choice Health Plan of New York">Easy Choice Health Plan of New York</option>
                                    <option value="El Paso First Health Plans">El Paso First Health Plans</option>
                                    <option value="Elderplan">Elderplan</option>
                                    <option value="EmblemHealth">EmblemHealth</option>
                                    <option value="EmblemHealth (formerly known as GHI)">EmblemHealth (formerly known as GHI)</option>
                                    <option value="EmblemHealth (formerly known as HIP)">EmblemHealth (formerly known as HIP)</option>
                                    <option value="Emory Health Care Plan">Emory Health Care Plan</option>
                                    <option value="Empire Blue Cross Blue Shield">Empire Blue Cross Blue Shield</option>
                                    <option value="Empire BlueCross BlueShield HealthPlus">Empire BlueCross BlueShield HealthPlus</option>
                                    <option value="Empire Plan">Empire Plan</option>
                                    <option value="Empower Healthcare Solutions">Empower Healthcare Solutions</option>
                                    <option value="Encore Health Network">Encore Health Network</option>
                                    <option value="Envolve Benefit Options">Envolve Benefit Options</option>
                                    <option value="Eon Health">Eon Health</option>
                                    <option value="Epic Hearing Health Care">Epic Hearing Health Care</option>
                                    <option value="Erickson Advantage">Erickson Advantage</option>
                                    <option value="EverCare">EverCare</option>
                                    <option value="Evergreen Health Cooperative">Evergreen Health Cooperative</option>
                                    <option value="Evolutions Healthcare Systems">Evolutions Healthcare Systems</option>
                                    <option value="Excellus Blue Cross Blue Shield">Excellus Blue Cross Blue Shield</option>
                                    <option value="Experience HealthND">Experience HealthND</option>
                                    <option value="Extended Managed Long Term Care">Extended Managed Long Term Care</option>
                                    <option value="EyeMed">EyeMed</option>
                                    <option value="Eyetopia Vision Care">Eyetopia Vision Care</option>
                                    <option value="Fallon Community Health Plan (FCHP)">Fallon Community Health Plan (FCHP)</option>
                                    <option value="Family Health Network">Family Health Network</option>
                                    <option value="FamilyCare Health Plans">FamilyCare Health Plans</option>
                                    <option value="Fidelis Care (NY)">Fidelis Care (NY)</option>
                                    <option value="First Choice Health">First Choice Health</option>
                                    <option value="First Choice Health Plan of Mississippi">First Choice Health Plan of Mississippi</option>
                                    <option value="First Health (Coventry Health Care)">First Health (Coventry Health Care)</option>
                                    <option value="FirstCare Health Plans">FirstCare Health Plans</option>
                                    <option value="FirstCarolinaCare">FirstCarolinaCare</option>
                                    <option value="Florida Blue: Blue Cross Blue Shield of Florida">Florida Blue: Blue Cross Blue Shield of Florida</option>
                                    <option value="Florida Community Care">Florida Community Care</option>
                                    <option value="Florida Health Care Plans">Florida Health Care Plans</option>
                                    <option value="Florida Health Partners">Florida Health Partners</option>
                                    <option value="Florida Hospital Healthcare System (FHHS)">Florida Hospital Healthcare System (FHHS)</option>
                                    <option value="Florida KidCare">Florida KidCare</option>
                                    <option value="Fort Bend County Indigent Health Care">Fort Bend County Indigent Health Care</option>
                                    <option value="Fortified Provider Network">Fortified Provider Network</option>
                                    <option value="Freedom Health">Freedom Health</option>
                                    <option value="Fresenius Health Plans">Fresenius Health Plans</option>
                                    <option value="Friday Health Plans">Friday Health Plans</option>
                                    <option value="GEHA">GEHA</option>
                                    <option value="GEMCare Health Plan">GEMCare Health Plan</option>
                                    <option value="GWH-Cigna (formerly Great West Healthcare)">GWH-Cigna (formerly Great West Healthcare)</option>
                                    <option value="Galaxy Health">Galaxy Health</option>
                                    <option value="Gateway Health">Gateway Health</option>
                                    <option value="Geisinger Health Plan">Geisinger Health Plan</option>
                                    <option value="General Vision Services (GVS)">General Vision Services (GVS)</option>
                                    <option value="GeoBlue">GeoBlue</option>
                                    <option value="Gilsbar 360 Alliance">Gilsbar 360 Alliance</option>
                                    <option value="Global Health">Global Health</option>
                                    <option value="Gold Coast Health Plan">Gold Coast Health Plan</option>
                                    <option value="Golden Rule">Golden Rule</option>
                                    <option value="Golden State Medicare Health Plan">Golden State Medicare Health Plan</option>
                                    <option value="Green Mountain Care (Vermont)">Green Mountain Care (Vermont)</option>
                                    <option value="Group Health Cooperative">Group Health Cooperative</option>
                                    <option value="Group Health Cooperative of Eau Claire">Group Health Cooperative of Eau Claire</option>
                                    <option value="Group Health Cooperative of South Central Wisconsin">Group Health Cooperative of South Central Wisconsin</option>
                                    <option value="Guardian">Guardian</option>
                                    <option value="Gundersen Health Plan">Gundersen Health Plan</option>
                                    <option value="HAP (Health Alliance Plan)">HAP (Health Alliance Plan)</option>
                                    <option value="HAP Midwest Health Plan">HAP Midwest Health Plan</option>
                                    <option value="HFN">HFN</option>
                                    <option value="HFS Medical Benefits">HFS Medical Benefits</option>
                                    <option value="HUSKY Health">HUSKY Health</option>
                                    <option value="Hamaspik Choice">Hamaspik Choice</option>
                                    <option value="Harken Health">Harken Health</option>
                                    <option value="Harmony Health Plan">Harmony Health Plan</option>
                                    <option value="Harvard Pilgrim Health Care">Harvard Pilgrim Health Care</option>
                                    <option value="Hawaii Medical Assurance Association (HMAA)">Hawaii Medical Assurance Association (HMAA)</option>
                                    <option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
                                    <option value="Health Alliance">Health Alliance</option>
                                    <option value="Health Choice Arizona">Health Choice Arizona</option>
                                    <option value="Health First (FL)">Health First (FL)</option>
                                    <option value="Health First Colorado">Health First Colorado</option>
                                    <option value="Health First Health Plans (Florida)">Health First Health Plans (Florida)</option>
                                    <option value="Health Net">Health Net</option>
                                    <option value="Health New England">Health New England</option>
                                    <option value="Health Partners Plans (Pennsylvania)">Health Partners Plans (Pennsylvania)</option>
                                    <option value="Health Plan of Nevada">Health Plan of Nevada</option>
                                    <option value="Health Plan of San Joaquin">Health Plan of San Joaquin</option>
                                    <option value="Health Plan of San Mateo">Health Plan of San Mateo</option>
                                    <option value="Health Plus">Health Plus</option>
                                    <option value="Health Share of Oregon">Health Share of Oregon</option>
                                    <option value="Health Sun">Health Sun</option>
                                    <option value="HealthChoice Oklahoma">HealthChoice Oklahoma</option>
                                    <option value="HealthChoice of Michigan">HealthChoice of Michigan</option>
                                    <option value="HealthFirst (NY)">HealthFirst (NY)</option>
                                    <option value="HealthNow">HealthNow</option>
                                    <option value="HealthPartners">HealthPartners</option>
                                    <option value="HealthScope Benefits">HealthScope Benefits</option>
                                    <option value="HealthSmart">HealthSmart</option>
                                    <option value="HealthTeam Advantage">HealthTeam Advantage</option>
                                    <option value="Healthcare Highways Health Plan">Healthcare Highways Health Plan</option>
                                    <option value="Healthlink">Healthlink</option>
                                    <option value="Healthy Texas Women">Healthy Texas Women</option>
                                    <option value="HealthyCT">HealthyCT</option>
                                    <option value="Hear In America">Hear In America</option>
                                    <option value="Hennepin Health">Hennepin Health</option>
                                    <option value="Heritage Vision Plans">Heritage Vision Plans</option>
                                    <option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
                                    <option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
                                    <option value="Highmark Blue Shield">Highmark Blue Shield</option>
                                    <option value="Highmark BlueCross BlueShield of West Virginia">Highmark BlueCross BlueShield of West Virginia</option>
                                    <option value="Hillsborough Health Care Plan">Hillsborough Health Care Plan</option>
                                    <option value="Home State Health Plan">Home State Health Plan</option>
                                    <option value="Hometown Health">Hometown Health</option>
                                    <option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
                                    <option value="Horizon Blue Cross Blue Shield of New Jersey For Novartis">Horizon Blue Cross Blue Shield of New Jersey For Novartis</option>
                                    <option value="Horizon NJ Health">Horizon NJ Health</option>
                                    <option value="Hudson Health Plan">Hudson Health Plan</option>
                                    <option value="Humana">Humana</option>
                                    <option value="Humana Behavioral Health (LifeSynch)">Humana Behavioral Health (LifeSynch)</option>
                                    <option value="IHC Health Solutions">IHC Health Solutions</option>
                                    <option value="IMS (Independent Medical Systems)">IMS (Independent Medical Systems)</option>
                                    <option value="IU Health Plans (Indiana University Health)">IU Health Plans (Indiana University Health)</option>
                                    <option value="Illinicare Health">Illinicare Health</option>
                                    <option value="Illinois' Primary Care Case Management (PCCM)">Illinois' Primary Care Case Management (PCCM)</option>
                                    <option value="Imagine Health">Imagine Health</option>
                                    <option value="Imperial Health Plan of California">Imperial Health Plan of California</option>
                                    <option value="Imperial Insurance Company of Texas">Imperial Insurance Company of Texas</option>
                                    <option value="Independence Blue Cross">Independence Blue Cross</option>
                                    <option value="Independence Care System">Independence Care System</option>
                                    <option value="Independent Health">Independent Health</option>
                                    <option value="Indiana Medicaid">Indiana Medicaid</option>
                                    <option value="Ingham Health Plan">Ingham Health Plan</option>
                                    <option value="Inland Empire Health Plan">Inland Empire Health Plan</option>
                                    <option value="Innovation Health">Innovation Health</option>
                                    <option value="Integra">Integra</option>
                                    <option value="Inter Valley Health Plan">Inter Valley Health Plan</option>
                                    <option value="InterCommunity Health Network CCO">InterCommunity Health Network CCO</option>
                                    <option value="Intergroup Services">Intergroup Services</option>
                                    <option value="Iowa MediPASS">Iowa MediPASS</option>
                                    <option value="Iowa Total Care">Iowa Total Care</option>
                                    <option value="Itasca Medical Care">Itasca Medical Care</option>
                                    <option value="Jackson Care Connect">Jackson Care Connect</option>
                                    <option value="Jackson Health Plan">Jackson Health Plan</option>
                                    <option value="Jai Medical Systems">Jai Medical Systems</option>
                                    <option value="Johns Hopkins Employer Health Programs">Johns Hopkins Employer Health Programs</option>
                                    <option value="KPS Health Plans">KPS Health Plans</option>
                                    <option value="Kaiser Permanente">Kaiser Permanente</option>
                                    <option value="Kansas HealthWave">Kansas HealthWave</option>
                                    <option value="Kansas Superior Select">Kansas Superior Select</option>
                                    <option value="KelseyCare Advantage">KelseyCare Advantage</option>
                                    <option value="Keystone First">Keystone First</option>
                                    <option value="L.A. Care Health Plan">L.A. Care Health Plan</option>
                                    <option value="L.A. Care Health Plan">L.A. Care Health Plan</option>
                                    <option value="Land of Lincoln Health">Land of Lincoln Health</option>
                                    <option value="Landmark Healthplan">Landmark Healthplan</option>
                                    <option value="Lasso Healthcare">Lasso Healthcare</option>
                                    <option value="Legacy Health">Legacy Health</option>
                                    <option value="Lehigh Valley Health Network Health Plan">Lehigh Valley Health Network Health Plan</option>
                                    <option value="Leon Medical Centers Health Plans">Leon Medical Centers Health Plans</option>
                                    <option value="Liberty Health Advantage">Liberty Health Advantage</option>
                                    <option value="Liberty HealthShare">Liberty HealthShare</option>
                                    <option value="Liberty Mutual">Liberty Mutual</option>
                                    <option value="LifeWise">LifeWise</option>
                                    <option value="Lifestyle Health">Lifestyle Health</option>
                                    <option value="Lighthouse Guild">Lighthouse Guild</option>
                                    <option value="Lighthouse Health Plan">Lighthouse Health Plan</option>
                                    <option value="Lincoln Financial Group">Lincoln Financial Group</option>
                                    <option value="Longevity Health Plan">Longevity Health Plan</option>
                                    <option value="Louisiana Healthcare Connections">Louisiana Healthcare Connections</option>
                                    <option value="Lutheran Preferred">Lutheran Preferred</option>
                                    <option value="MCM Maxcare">MCM Maxcare</option>
                                    <option value="MDwise">MDwise</option>
                                    <option value="MHNet Behavioral Health">MHNet Behavioral Health</option>
                                    <option value="MINES &amp; Associates">MINES &amp; Associates</option>
                                    <option value="MMM of Florida (Medicare and Much More)">MMM of Florida (Medicare and Much More)</option>
                                    <option value="MO HealthNet">MO HealthNet</option>
                                    <option value="MOAA (Miltary Officers Association of America)">MOAA (Miltary Officers Association of America)</option>
                                    <option value="MVP Health Care">MVP Health Care</option>
                                    <option value="Magellan Health">Magellan Health</option>
                                    <option value="MagnaCare">MagnaCare</option>
                                    <option value="Magnolia Health Plan">Magnolia Health Plan</option>
                                    <option value="Mail Handlers Benefit Plan">Mail Handlers Benefit Plan</option>
                                    <option value="MaineCare">MaineCare</option>
                                    <option value="Managed Health Network (MHN)">Managed Health Network (MHN)</option>
                                    <option value="Managed Health Services (Indiana)">Managed Health Services (Indiana)</option>
                                    <option value="Managed Health Services (Wisconsin)">Managed Health Services (Wisconsin)</option>
                                    <option value="Managed HealthCare Northwest">Managed HealthCare Northwest</option>
                                    <option value="March Vision Care">March Vision Care</option>
                                    <option value="Maricopa Health Plan">Maricopa Health Plan</option>
                                    <option value="Martin's Point HealthCare">Martin's Point HealthCare</option>
                                    <option value="Maryland Medical Assistance (Medicaid)">Maryland Medical Assistance (Medicaid)</option>
                                    <option value="Maryland Physicians Care">Maryland Physicians Care</option>
                                    <option value="MassHealth">MassHealth</option>
                                    <option value="Massachusetts Laborers' Health &amp; Welfare Fund">Massachusetts Laborers' Health &amp; Welfare Fund</option>
                                    <option value="Mayo Medical Plan">Mayo Medical Plan</option>
                                    <option value="McLaren Health Plan">McLaren Health Plan</option>
                                    <option value="MedStar Family Choice">MedStar Family Choice</option>
                                    <option value="MedStar Select">MedStar Select</option>
                                    <option value="Medi-Cal">Medi-Cal</option>
                                    <option value="MediGold">MediGold</option>
                                    <option value="MediPass">MediPass</option>
                                    <option value="Medica">Medica</option>
                                    <option value="Medica HealthCare Plans (Florida)">Medica HealthCare Plans (Florida)</option>
                                    <option value="Medicaid">Medicaid</option>
                                    <option value="Medical Eye Services (MES Vision)">Medical Eye Services (MES Vision)</option>
                                    <option value="Medical Mutual">Medical Mutual</option>
                                    <option value="Medicare">Medicare</option>
                                    <option value="Memorial Healthcare System">Memorial Healthcare System</option>
                                    <option value="Memorial Hermann">Memorial Hermann</option>
                                    <option value="Mercy Care">Mercy Care</option>
                                    <option value="Meridian Health Plan">Meridian Health Plan</option>
                                    <option value="Meritain Health">Meritain Health</option>
                                    <option value="MetLife">MetLife</option>
                                    <option value="MetroHealth">MetroHealth</option>
                                    <option value="MetroPlus Health Plan">MetroPlus Health Plan</option>
                                    <option value="Metropolitan Health Plan">Metropolitan Health Plan</option>
                                    <option value="Miami Children's Health Plan">Miami Children's Health Plan</option>
                                    <option value="Michigan Complete Health">Michigan Complete Health</option>
                                    <option value="Michigan No-Fault">Michigan No-Fault</option>
                                    <option value="Minuteman Health">Minuteman Health</option>
                                    <option value="Mississippi Division of Medicaid">Mississippi Division of Medicaid</option>
                                    <option value="Missouri Care">Missouri Care</option>
                                    <option value="Moda Health">Moda Health</option>
                                    <option value="Molina Healthcare">Molina Healthcare</option>
                                    <option value="Montana Health Cooperative">Montana Health Cooperative</option>
                                    <option value="Montefiore HMO">Montefiore HMO</option>
                                    <option value="Mountain Health Co-Op">Mountain Health Co-Op</option>
                                    <option value="Multiplan PHCS">Multiplan PHCS</option>
                                    <option value="Mutual of Omaha">Mutual of Omaha</option>
                                    <option value="NALC Health Benefit Plan">NALC Health Benefit Plan</option>
                                    <option value="NECA/IBEW Family Medical Care Plan">NECA/IBEW Family Medical Care Plan</option>
                                    <option value="NY State No-Fault">NY State No-Fault</option>
                                    <option value="NY: YourCare Health Plan">NY: YourCare Health Plan</option>
                                    <option value="National Congress of Employers (NCE)">National Congress of Employers (NCE)</option>
                                    <option value="National Vision Administrators">National Vision Administrators</option>
                                    <option value="Nationwide">Nationwide</option>
                                    <option value="Navajo Nation">Navajo Nation</option>
                                    <option value="Nebraska Total Care (Heritage Health)">Nebraska Total Care (Heritage Health)</option>
                                    <option value="Neighborhood Health Plan (Massachusetts)">Neighborhood Health Plan (Massachusetts)</option>
                                    <option value="Neighborhood Health Plan of Rhode Island">Neighborhood Health Plan of Rhode Island</option>
                                    <option value="Network Health Plan">Network Health Plan</option>
                                    <option value="Nevada Preferred">Nevada Preferred</option>
                                    <option value="New Directions Behavioral Health">New Directions Behavioral Health</option>
                                    <option value="New Hampshire Healthy Families">New Hampshire Healthy Families</option>
                                    <option value="New Mexico Health Connections">New Mexico Health Connections</option>
                                    <option value="New York Hotel Trades Council">New York Hotel Trades Council</option>
                                    <option value="NextLevelHealth">NextLevelHealth</option>
                                    <option value="Nippon Life Benefits">Nippon Life Benefits</option>
                                    <option value="North Carolina Health Choice (NCHC) for Children">North Carolina Health Choice (NCHC) for Children</option>
                                    <option value="North Shore LIJ CareConnect">North Shore LIJ CareConnect</option>
                                    <option value="Northland PACE">Northland PACE</option>
                                    <option value="NovaNet">NovaNet</option>
                                    <option value="OHMS (Oregon Health Management Services)">OHMS (Oregon Health Management Services)</option>
                                    <option value="OSU Health Plan">OSU Health Plan</option>
                                    <option value="Ohara, LLC">Ohara, LLC</option>
                                    <option value="Ohio Health Choice">Ohio Health Choice</option>
                                    <option value="OhioHealthy">OhioHealthy</option>
                                    <option value="On Lok Lifeways">On Lok Lifeways</option>
                                    <option value="On Lok Lifeways (PACE)">On Lok Lifeways (PACE)</option>
                                    <option value="OneNet PPO">OneNet PPO</option>
                                    <option value="Opticare of Utah">Opticare of Utah</option>
                                    <option value="Optima Health">Optima Health</option>
                                    <option value="Optimum HealthCare">Optimum HealthCare</option>
                                    <option value="Optum Health">Optum Health</option>
                                    <option value="Oscar Health Insurance Co.">Oscar Health Insurance Co.</option>
                                    <option value="Oxford (UnitedHealthcare)">Oxford (UnitedHealthcare)</option>
                                    <option value="PA Health and Wellness">PA Health and Wellness</option>
                                    <option value="PA Medical Assistance">PA Medical Assistance</option>
                                    <option value="PBA (Patrolmen's Benefit Association)">PBA (Patrolmen's Benefit Association)</option>
                                    <option value="POMCO">POMCO</option>
                                    <option value="Pacific Health Alliance">Pacific Health Alliance</option>
                                    <option value="PacificSource Health Plans">PacificSource Health Plans</option>
                                    <option value="Palmetto GBA">Palmetto GBA</option>
                                    <option value="Pan-American Life Insurance Group">Pan-American Life Insurance Group</option>
                                    <option value="Paradigm Senior Care Advantage">Paradigm Senior Care Advantage</option>
                                    <option value="Paramount Healthcare">Paramount Healthcare</option>
                                    <option value="Parkland Community Health Plan">Parkland Community Health Plan</option>
                                    <option value="Parkview Total Health">Parkview Total Health</option>
                                    <option value="Partners Health Plan">Partners Health Plan</option>
                                    <option value="Partnership HealthPlan of California">Partnership HealthPlan of California</option>
                                    <option value="Passport Health Plan (Kentucky)">Passport Health Plan (Kentucky)</option>
                                    <option value="Passport To Health (Montana Medicaid)">Passport To Health (Montana Medicaid)</option>
                                    <option value="Patient 1st (Alabama Medicaid)">Patient 1st (Alabama Medicaid)</option>
                                    <option value="Peach State Health Plan">Peach State Health Plan</option>
                                    <option value="PeachCare for Kids">PeachCare for Kids</option>
                                    <option value="PennCare">PennCare</option>
                                    <option value="Peoples Health">Peoples Health</option>
                                    <option value="Phoenix Health Plan">Phoenix Health Plan</option>
                                    <option value="Physician Assured Access System">Physician Assured Access System</option>
                                    <option value="Physician Benefits Trust">Physician Benefits Trust</option>
                                    <option value="Physicians Health Plan">Physicians Health Plan</option>
                                    <option value="Physicians Health Plan of Northern Indiana, Inc.">Physicians Health Plan of Northern Indiana, Inc.</option>
                                    <option value="PhysiciansCare">PhysiciansCare</option>
                                    <option value="Piedmont Community Health Plan">Piedmont Community Health Plan</option>
                                    <option value="Piedmont WellStar Health Plans">Piedmont WellStar Health Plans</option>
                                    <option value="Positive Health Care">Positive Health Care</option>
                                    <option value="Preferential Care Network">Preferential Care Network</option>
                                    <option value="Preferred Care Partners">Preferred Care Partners</option>
                                    <option value="PreferredOne">PreferredOne</option>
                                    <option value="Premera Blue Cross">Premera Blue Cross</option>
                                    <option value="Premier Health Plan">Premier Health Plan</option>
                                    <option value="Presbyterian Health Plan/Presbyterian Insurance Company">Presbyterian Health Plan/Presbyterian Insurance Company</option>
                                    <option value="Prestige Health Choice">Prestige Health Choice</option>
                                    <option value="Primary Care Case Management (North Dakota Medicaid)">Primary Care Case Management (North Dakota Medicaid)</option>
                                    <option value="Prime Health Services, Inc">Prime Health Services, Inc</option>
                                    <option value="Prime Healthcare">Prime Healthcare</option>
                                    <option value="PrimeWest Health">PrimeWest Health</option>
                                    <option value="Principal Financial Group">Principal Financial Group</option>
                                    <option value="Priority Health">Priority Health</option>
                                    <option value="Priority Partners">Priority Partners</option>
                                    <option value="Progressive">Progressive</option>
                                    <option value="Prominence Health Plan">Prominence Health Plan</option>
                                    <option value="ProviDRs Care (WPPA)">ProviDRs Care (WPPA)</option>
                                    <option value="Providence Health Plans">Providence Health Plans</option>
                                    <option value="Provider Partners Health Plan">Provider Partners Health Plan</option>
                                    <option value="Public Aid (Illinois Medicaid)">Public Aid (Illinois Medicaid)</option>
                                    <option value="Public Employees Health Program (PEHP)">Public Employees Health Program (PEHP)</option>
                                    <option value="Puget Sound Electrical Workers Trusts">Puget Sound Electrical Workers Trusts</option>
                                    <option value="QualCare">QualCare</option>
                                    <option value="QualChoice Arkansas">QualChoice Arkansas</option>
                                    <option value="Quality Health Plans of New York">Quality Health Plans of New York</option>
                                    <option value="Quartz">Quartz</option>
                                    <option value="Quest Behavioral Health">Quest Behavioral Health</option>
                                    <option value="Quiktrip">Quiktrip</option>
                                    <option value="RLI Indemnity Company">RLI Indemnity Company</option>
                                    <option value="Regence Blue Cross Blue Shield">Regence Blue Cross Blue Shield</option>
                                    <option value="Regent Insurance">Regent Insurance</option>
                                    <option value="Reliance Medicare Advantage">Reliance Medicare Advantage</option>
                                    <option value="Renaissance">Renaissance</option>
                                    <option value="Republic-Franklin Insurance">Republic-Franklin Insurance</option>
                                    <option value="RiverLink Health">RiverLink Health</option>
                                    <option value="RiverSpring Health Plans">RiverSpring Health Plans</option>
                                    <option value="Riverside Health">Riverside Health</option>
                                    <option value="Rockefeller Health Plan">Rockefeller Health Plan</option>
                                    <option value="Rocky Mountain Health Plans">Rocky Mountain Health Plans</option>
                                    <option value="SAG AFTRA Health Plan">SAG AFTRA Health Plan</option>
                                    <option value="SAMBA">SAMBA</option>
                                    <option value="SCAN Health Plan">SCAN Health Plan</option>
                                    <option value="SIHO Insurance Services">SIHO Insurance Services</option>
                                    <option value="SSM Health Care">SSM Health Care</option>
                                    <option value="Sagamore Health Network">Sagamore Health Network</option>
                                    <option value="Samaritan Health Plan Operations">Samaritan Health Plan Operations</option>
                                    <option value="San Francisco Health Plan">San Francisco Health Plan</option>
                                    <option value="Sanford Health Plan">Sanford Health Plan</option>
                                    <option value="Santa Clara Family Health Plan">Santa Clara Family Health Plan</option>
                                    <option value="Scott &amp; White Health Plan">Scott &amp; White Health Plan</option>
                                    <option value="Security Health Plan of Wisconsin, Inc.">Security Health Plan of Wisconsin, Inc.</option>
                                    <option value="Select Care">Select Care</option>
                                    <option value="Select Health Network">Select Health Network</option>
                                    <option value="Select Health of South Carolina">Select Health of South Carolina</option>
                                    <option value="SelectHealth">SelectHealth</option>
                                    <option value="Sendero Health Plans">Sendero Health Plans</option>
                                    <option value="Seneca Insurance">Seneca Insurance</option>
                                    <option value="Senior Dimensions">Senior Dimensions</option>
                                    <option value="Senior Whole Health">Senior Whole Health</option>
                                    <option value="Sentry Insurance">Sentry Insurance</option>
                                    <option value="Seton Health Plan">Seton Health Plan</option>
                                    <option value="Sharp Health Plan">Sharp Health Plan</option>
                                    <option value="Sierra Health and Life">Sierra Health and Life</option>
                                    <option value="SightCare">SightCare</option>
                                    <option value="SilverSummit Healthplan">SilverSummit Healthplan</option>
                                    <option value="Simply Healthcare">Simply Healthcare</option>
                                    <option value="Simpra Advantage">Simpra Advantage</option>
                                    <option value="Solis Health Plans">Solis Health Plans</option>
                                    <option value="Solstice">Solstice</option>
                                    <option value="SoonerCare (Oklahoma Medicaid)">SoonerCare (Oklahoma Medicaid)</option>
                                    <option value="Soundpath Health">Soundpath Health</option>
                                    <option value="South Country Health Alliance">South Country Health Alliance</option>
                                    <option value="South Florida Community Care Network">South Florida Community Care Network</option>
                                    <option value="Southwestern Health Resources (SWHR)">Southwestern Health Resources (SWHR)</option>
                                    <option value="Spectera">Spectera</option>
                                    <option value="Standard Life and Accident Insurance Company">Standard Life and Accident Insurance Company</option>
                                    <option value="Stanford Health Care Advantage">Stanford Health Care Advantage</option>
                                    <option value="StarNet Insurance">StarNet Insurance</option>
                                    <option value="State Farm®">State Farm®</option>
                                    <option value="State National Insurance">State National Insurance</option>
                                    <option value="Staywell Insurance">Staywell Insurance</option>
                                    <option value="Steward Health Care Network - Health Choice Arizona">Steward Health Care Network - Health Choice Arizona</option>
                                    <option value="Steward Health Choice">Steward Health Choice</option>
                                    <option value="Stratose">Stratose</option>
                                    <option value="SummaCare">SummaCare</option>
                                    <option value="Summit Community Care">Summit Community Care</option>
                                    <option value="Sunflower Health Plan">Sunflower Health Plan</option>
                                    <option value="Sunrise Advantage Plan">Sunrise Advantage Plan</option>
                                    <option value="Sunshine Health">Sunshine Health</option>
                                    <option value="Superior HealthPlan">Superior HealthPlan</option>
                                    <option value="Superior Vision">Superior Vision</option>
                                    <option value="Sussex Insurance">Sussex Insurance</option>
                                    <option value="Sutter Health Plus">Sutter Health Plus</option>
                                    <option value="SutterSelect">SutterSelect</option>
                                    <option value="TNUS Insurance">TNUS Insurance</option>
                                    <option value="TakeCare">TakeCare</option>
                                    <option value="Teachers Health Trust">Teachers Health Trust</option>
                                    <option value="TexanPlus">TexanPlus</option>
                                    <option value="Texas Children's Health Plan">Texas Children's Health Plan</option>
                                    <option value="Texas Health Aetna">Texas Health Aetna</option>
                                    <option value="Texas Kids First">Texas Kids First</option>
                                    <option value="The HSC Health Care System">The HSC Health Care System</option>
                                    <option value="The Hartford">The Hartford</option>
                                    <option value="The Health Plan of the Upper Ohio Valley, Inc.">The Health Plan of the Upper Ohio Valley, Inc.</option>
                                    <option value="Three Rivers Providers Network (TRPN)">Three Rivers Providers Network (TRPN)</option>
                                    <option value="Total Health Care">Total Health Care</option>
                                    <option value="Touchstone">Touchstone</option>
                                    <option value="Transamerica">Transamerica</option>
                                    <option value="Travelers">Travelers</option>
                                    <option value="Tricare">Tricare</option>
                                    <option value="Trillium Community Health Plan">Trillium Community Health Plan</option>
                                    <option value="Trilogy Health Insurance">Trilogy Health Insurance</option>
                                    <option value="Triple-S Salud: Blue Cross Blue Shield of Puerto Rico">Triple-S Salud: Blue Cross Blue Shield of Puerto Rico</option>
                                    <option value="Triwest Healthcare Alliance">Triwest Healthcare Alliance</option>
                                    <option value="TrueHealth New Mexico">TrueHealth New Mexico</option>
                                    <option value="Trusted Health Plan">Trusted Health Plan</option>
                                    <option value="Tuality Health Alliance">Tuality Health Alliance</option>
                                    <option value="Tufts Health Freedom Plan">Tufts Health Freedom Plan</option>
                                    <option value="Tufts Health Plan">Tufts Health Plan</option>
                                    <option value="UCHP (University of Chicago Health Plan)">UCHP (University of Chicago Health Plan)</option>
                                    <option value="UCare">UCare</option>
                                    <option value="UHA Health Insurance">UHA Health Insurance</option>
                                    <option value="ULLICO Casualty Company">ULLICO Casualty Company</option>
                                    <option value="UPMC Health Plan">UPMC Health Plan</option>
                                    <option value="US Family Health Plan">US Family Health Plan</option>
                                    <option value="US Health Group">US Health Group</option>
                                    <option value="USA Managed Care Organization">USA Managed Care Organization</option>
                                    <option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
                                    <option value="Ultimate Health Plans">Ultimate Health Plans</option>
                                    <option value="Umpqua Health Alliance">Umpqua Health Alliance</option>
                                    <option value="UniCare">UniCare</option>
                                    <option value="Uniform Medical Plan">Uniform Medical Plan</option>
                                    <option value="Union Eye Care">Union Eye Care</option>
                                    <option value="Union Health Services, Inc">Union Health Services, Inc</option>
                                    <option value="Union Plans">Union Plans</option>
                                    <option value="United American">United American</option>
                                    <option value="United Behavioral Health">United Behavioral Health</option>
                                    <option value="UnitedHealthOne">UnitedHealthOne</option>
                                    <option value="UnitedHealthcare">UnitedHealthcare</option>
                                    <option value="UnitedHealthcare Community Plan">UnitedHealthcare Community Plan</option>
                                    <option value="UnitedHealthcare Oxford">UnitedHealthcare Oxford</option>
                                    <option value="Unity Health Insurance">Unity Health Insurance</option>
                                    <option value="Univera Healthcare">Univera Healthcare</option>
                                    <option value="Universal American">Universal American</option>
                                    <option value="Universal Underwriters Insurance">Universal Underwriters Insurance</option>
                                    <option value="University Hospitals (Health Design Plus)">University Hospitals (Health Design Plus)</option>
                                    <option value="University Physician Network (UPN)">University Physician Network (UPN)</option>
                                    <option value="University of Arizona Health Plans">University of Arizona Health Plans</option>
                                    <option value="University of Maryland Health Advantage">University of Maryland Health Advantage</option>
                                    <option value="University of Maryland Health Partners">University of Maryland Health Partners</option>
                                    <option value="University of Utah Health Plans">University of Utah Health Plans</option>
                                    <option value="Upper Peninsula Health Plan">Upper Peninsula Health Plan</option>
                                    <option value="VNS Choice Health Plans">VNS Choice Health Plans</option>
                                    <option value="VSP">VSP</option>
                                    <option value="Valley Forge Insurance">Valley Forge Insurance</option>
                                    <option value="Valley Health Plan">Valley Health Plan</option>
                                    <option value="Valor Health Plan">Valor Health Plan</option>
                                    <option value="Vantage Health Plan, Inc.">Vantage Health Plan, Inc.</option>
                                    <option value="Ventura County Health Care Plan">Ventura County Health Care Plan</option>
                                    <option value="Vibra Health Plan">Vibra Health Plan</option>
                                    <option value="VillageCareMax">VillageCareMax</option>
                                    <option value="Virginia Coordinated Care (VCC)">Virginia Coordinated Care (VCC)</option>
                                    <option value="Virginia Health Network">Virginia Health Network</option>
                                    <option value="Virginia Premier Health Plan">Virginia Premier Health Plan</option>
                                    <option value="Vision Benefits of America">Vision Benefits of America</option>
                                    <option value="Vision Care Direct">Vision Care Direct</option>
                                    <option value="Vision Plan of America">Vision Plan of America</option>
                                    <option value="Viva Health Plan">Viva Health Plan</option>
                                    <option value="Vivida Health">Vivida Health</option>
                                    <option value="Volusia Health Network">Volusia Health Network</option>
                                    <option value="Vytra">Vytra</option>
                                    <option value="WEA Trust">WEA Trust</option>
                                    <option value="WPS Health Plan">WPS Health Plan</option>
                                    <option value="WRM America Indemnity Company">WRM America Indemnity Company</option>
                                    <option value="Well Sense Health Plan">Well Sense Health Plan</option>
                                    <option value="WellFirst Health">WellFirst Health</option>
                                    <option value="Wellcare">Wellcare</option>
                                    <option value="Wellmark Blue Cross Blue Shield">Wellmark Blue Cross Blue Shield</option>
                                    <option value="West American Insurance">West American Insurance</option>
                                    <option value="West Virginia Senior Advantage">West Virginia Senior Advantage</option>
                                    <option value="Western Health Advantage">Western Health Advantage</option>
                                    <option value="Western Sky Community Care">Western Sky Community Care</option>
                                    <option value="Willamette Valley Community Health">Willamette Valley Community Health</option>
                                    <option value="Workers' Compensation">Workers' Compensation</option>
                                    <option value="Yamhill Community Care Organization">Yamhill Community Care Organization</option>
                                    <option value="Zenith">Zenith</option>
                                </select>
                            </div>
                            <div class='form-group mb-3'>
                                <label class='control-label'>Member ID</label>
                                <input class='form-control' type='text' name='mbPayerMemberId'>
                            </div>
                        </div>
                        <hr class="m-neg-4">
			<div class='form-group mb-3'>
                            <label class='control-label'>How did you hear about us?</label>
                            <textarea class='form-control' type='text' required="" name='initiative'></textarea>
                        </div>
                    </form>
                </div>
                <div class="card-footer">
                    <button class="btn btn-primary" submit>Create New Patient</button>
                </div>
            </div>
        </div>
    </div>

    <link href="/select2/select2.min.css" rel="stylesheet" />
    <script src="/select2/select2.min.js"></script>
    <script src="/inputmask-5.x/dist/inputmask.js"></script>
    <script>
        (function() {
            function init() {
                let im = new Inputmask("(999) 999-9999").mask('[stag-input-phone]');
                $(document)
                    .off('click.hpn-to-cpn', '.hpn-to-cpn')
                    .on('click.hpn-to-cpn', '.hpn-to-cpn', function() {
                        $('[name="cellNumber"]').val($('[name="homeNumber"]').val());
                        $('[name="homeNumber"]').val('');
                        return false;
                    });
                $(document)
                    .off('click.cpn-to-hpn', '.cpn-to-hpn')
                    .on('click.cpn-to-hpn', '.cpn-to-hpn', function() {
                        $('[name="homeNumber"]').val($('[name="cellNumber"]').val());
                        $('[name="cellNumber"]').val('');
                        return false;
                    });
                $(document)
                    .off('click.swap-pns', '.swap-pns')
                    .on('click.swap-pns', '.swap-pns', function() {
                        let hpn = $('[name="homeNumber"]').val();
                        $('[name="homeNumber"]').val($('[name="cellNumber"]').val());
                        $('[name="cellNumber"]').val(hpn);
                        return false;
                    });
                $(document)
                    .off('change.insurance', '.insurance')
                    .on('change.insurance', '.insurance', function() {
                        $('[data-insurance]').addClass('d-none');
                        $('[data-insurance="' + $(this).val() + '"]').removeClass('d-none');
                        $(this).closest('form').attr('url', '/api/client/' + ($(this).val() === 'medicare' ? 'create' : 'createNonMcn'))
                        $(this).closest('[moe]').removeAttr('initialized');
                        initMoes();
                        return false;
                    });
                $('.select2').select2({
                    width: '100%'
                });
            }
            addMCInitializer('new-patient', init, '#newPatientContainer');
        }).call(window);
    </script>

@endsection